HMSC ME Hassell

Date: 03/02/2025 Inner North London St Pancras Coroner’s Court Camley Street London N1C 4PP

Sent via email: ST MUNGO’S HOUSING ASSOCIATION’S RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: INQUEST INTO THE DEATH OF NONI ATISHKI Introduction:
1. I refer to your Report to Prevent Future Deaths dated 12 December 2024 (the “PFD Report”), concerning the death of Noni Atishki, who sadly died on 13 July 2024.

2. I am replying as the CEO of St Mungo’s Community Housing Association (“St Mungo’s”).

3. At the outset of this response, I would like to express my sincere condolences to the family of Noni Atishki.

4. This inquest and the PFD Report has led to significant reflection within St Mungo’s, with extensive discussions held within our Client Services, Quality, Health and Safety, Learning and Development, Governance and Compliance departments around learnings and improvements that we can implement internally.

5. At the heart of our services is our commitment to doing everything we can to keep our clients safe, to empower them in their individual recovery journeys and to prevent homelessness in the future. When a death occurs within our services, we are dedicated to understanding what happened and to taking actionable steps to implement meaningful changes and improvements where necessary.

6. In this response, I outline the nature of St Mungo’s services, the charity’s duties, and the policies, procedures and practices we have in place to ensure the safety and well-being of our clients. I then address the specific concerns raised in the PFD Report surrounding the circumstances of Noni Atishki’s death and detail the actions we have taken or plan to take to improve our practice where relevant.

7. Please note that I have not enclosed the policies and procedures that I have referenced throughout this response. However, these can be provided to you if you wish to see these.

The nature of St Mungo’s services:
8. St Mungo’s is a charity that provides support and accommodation to those affected by homelessness. The organisation delivers a number of services across London and the South- East and South-West of England, and is largely contracted to operate said services by individual Local Authorities.

9. St. Mungo’s delivers a range of services; from preventative services that support people whose tenancies are at risk, to outreach teams working with individuals who are experiencing a period of rough sleeping, through to accommodation services and support for people to move on to more settled housing. We work with individuals who all have different stories and backgrounds, but predominantly people with high support needs, be they related to physical or mental health, drug or alcohol addiction, a history of offending, domestic abuse or immigration support needs. As an organisation, we therefore prioritise working in partnership with, or signposting people to, a wide range of specialist services to deliver the support that our clients need.

The Endell Street service:

10. Noni Atishki was a client of St Mungo’s Endell Street service at the time of her death. This service is what we would describe as a ‘first-stage’ hostel, in that the service accepts referrals from the Camden outreach team for people who are sleeping rough, and from the Camden Homeless Persons Service for people who have presented to the Local Authority as homeless and have been assessed as requiring accommodation with support. Clients of the service may

then move into their own independent accommodation directly from Endell Street or may move to other forms of supported housing dependent on their needs and the individual support plan formed with the client.

11. As a service, Endell Street provides accommodation and support for 53 homeless single men and women as part of the Camden Hostels Pathway. The staff at the service work with people at various stages of their journey from homelessness, supporting residents to move through the Pathway stages towards greater independence.

12. The service works in partnership with a range of external agencies in Camden that offer specialist support around mental health and substance use.

13. Each client has a named keyworker who is responsible for supporting the working shift pattern of the hostel, whilst supporting a case load of multiple disadvantaged clients. There are seven keyworkers on the team, each of whom work with eight clients at any one time. They are supported by two Deputy Managers and a Service Manager.

14. The Endell Street team values a relationship-based approach to working with people experiencing homelessness. Every individual client has their own personalised support plan and safety plan in which their support needs and risks around them are recorded and agreed, alongside actions aiming to promote the person’s recovery.

15. In general terms, clients at Endell Street are typically receiving support in two or more of the following areas: - mental health, physical health, substance use, offending and managing relationships, and staff support them to work towards managing an independent tenancy of their own in future.

16. The service is staffed 24 hours a day with a minimum staffing cover of two staff on duty at all times with additional staff available Monday to Friday during office hours (9:00-17:00). We have a separate night team of four waking night staff (two of whom are on duty at any one time), a cleaning and maintenance team, an apprentice and a duty worker supporting the day to day activities of the service.

Duties placed upon St Mungo’s and the policies and procedures we have in place:
17. I note that you will be familiar with the statutory duties owed by Local Authorities generally and by providers of clinical services on behalf of Local Authorities and the NHS. It is important to point out that St Mungo’s position is different from other such parties in two key respects. First, the charity does not adopt the duties owed by Local Authorities, for example under the Homelessness Reduction Act 2017 - we simply provide certain specified services to Local Authorities.

18. As touched upon above, the Endell Street service is commissioned as a ‘first stage’ hostel for individuals exiting a period rough sleeping, who require a medium to high level of support from staff on site. The service is commissioned by the Local Authority of Camden’s Commissioning team, as part of their ‘Adult Pathway’.

19. Second, save for two of our CQC registered care homes, no other services within St Mungo’s provides any regulated care or clinical services under The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It is also relevant to note that clients are not detained under any of the Mental Health Act provisions at any point during the time a client is a resident with St Mungo’s.

20. Nevertheless, St Mungo’s does have a duty to carry out its services safely and to ensure that those affected by its undertaking are not exposed to risks to their health and safety, so far as it reasonably practicable, pursuant to the Health & Safety at Work etc Act 1974.

21. In respect of the duty to carry out its services safely, St Mungo’s fulfils these duties by working with clients to identify their needs. This is achieved though systematic Client Needs Assessment and Action Planning and we have policies and procedures to outline this process. Noni had identified needs in a number of areas of her life but did not wish to be referred to external services for tailored support. Her Keyworker regularly reviewed with her whether she would be interested in support from the Camden drugs and alcohol services, provided by CGL in the borough of Camden, but she declined to be referred. She was supported to register with a community GP at The Museum Practice and was working with her GP around her physical health concerns at the time of her death.

22. While the Charity’s work shows that it is changing outcomes for its services users, the extent of its legal duties is limited in accordance with the nature and specification of the services it provides. However, in respect of the risks arising from substance abuse, St Mungo’s policies and procedures are fully cognisant of the fact that where multiple persons with substance or alcohol abuse issues will be living near each other, this is a risk that does arise from its undertaking and that it must therefore take reasonable steps to mitigate this risk.

23. To further mitigate this risk, particularly in relation to the risk of drug use and overdose – a key concern touched upon in your PFD Report - we have the following policies, procedures and practices in place:

24. First aid -
i. St Mungo’s has a First Aid Policy and Procedure.

ii. Where new staff do not already hold a relevant First Aid qualification, St Mungo’s aims for all client-facing staff to obtain a First Aid at Work Certificate or Emergency First Aid at Work Certificate within 6 months of starting employment.

iii. A Service Manager is responsible for ensuring that staff at their service attend training as soon as possible after starting work, in circumstances where they do not hold a relevant First Aid Qualification. St Mungo’s has a Learning and Development Team who manage the availability of training.

iv. The Learning and Development team reviews the training provision and attendance numbers every week to ensure that as courses fill up, additional training sessions are scheduled. They monitor attendance by booking an initial series of dates, tracking uptake, and adding new dates as needed to ensure people can book sessions within their first six months. Their goal is to have courses available within a rolling three-month window.

v. St Mungo’s Head of Safety and Quality Assurance reviews compliance with First Aid training quarterly and reports the findings to our Client Services Committee. Compliance is also discussed with the Learning and Development Team to ensure strategies are effective in improving compliance with training. For example, it was agreed to add First Aid training to our Solid Foundations process (refer to point 27 below) to provide clarity around the requirements and the ability to monitor compliance, and additional training dates have been booked to meet upcoming requests.

vi. Under the First Aid Policy and Procedure, St Mungo’s definition of a First Aider is a person who has completed a 3-day First Aid at Work course within the last 3 years and been certified as competent by the training provider. An Emergency First Aider at work is defined to be a person who has completed a 1-day Emergency First Aid at Work course within the last three years and been assessed as competent by the training provider. Therefore, we will accept if someone has completed such courses externally within the last three years, provided they were delivered by an appropriate provider, and all relevant criteria have been met.

25. Administering Naloxone -
i. St Mungo’s has a Drugs Policy and Procedure in place. As well as setting out St Mungo’s approach to ensuring the prevention of drug use within its services, the Drugs Procedure sets out St Mungo’s policy in relation to responding to an overdose and the administration of Naloxone. The Procedure requires that in the event of a client overdosing, staff should immediately call 999 and never delay calling an ambulance or administering First Aid.

ii. St Mungo’s also have an Overdose and Naloxone Information Booklet, referenced in our Drugs Procedure, in which the step-by-step process to follow is set out. The process includes calling an ambulance, performing basic life support (such as chest compressions) and administering Naloxone. It also advises staff to seek assistance from the operator if unsure about how to administer Naloxone. Instructions on CPR are also included.

iii. Staff can also contact the local prescribing team for information on Naloxone training for staff and clients.

iv. We have "How to obtain Naloxone for your service" guidance, along with additional resources and guidelines for staff, including rules about drug use and the law.

v. We have a Complex Needs Team within St Mungo’s who provide significant resources on drug and alcohol use on our intranet, including info-sheets on various drugs, handbooks and other materials.
vi. The Complex Needs Team also provide sessions for teams and clients covering overdose and Naloxone (on request).
vii. The Safety and Quality Assurance team is responsible for updating the Drugs Policy and collaborates with the Complex Needs Team in this process. The Safety and Quality Assurance team also collaborates annually on the review of deaths by overdose and agrees on a plan to try to reduce these. Last year, this included encouraging all staff to utilise existing tools, such as the Housing Opiate Overdose Risk Assessment tool, and engage clients in discussions about risk reduction strategies. The Complex Needs Team is always available to assist staff in devising more effective Safety and Wellbeing Plans focused on risk mitigation.

viii. We also created a 2024-25 forward plan, where we agreed on actions including: the Complex Needs Team will continue to provide support for incidents logged as overdoses; we will finalise and publish the Alcohol Management guidance; and we will publish Learning from Deaths Reviews to disseminate learnings within the organisation.
26. Other training –

i. All client-facing staff and managers are required to complete "Responding to emergencies" e-learning within the first three months of joining St Mungo’s. Amongst other modules, this training includes the following:

• A module called "medical emergencies and overdose." This module outlines the actions to be taken in the case of an overdose, including calling emergency services and that "The 999 switchboard may ask for certain things to be done. You should also consider a number of actions after you are assured an ambulance is on its way." These actions may include rescue breaths. Regarding overdose, the module says, "You should follow the steps detailed above and contact 999 to call an ambulance. In addition, you can use Naloxone if available at your service." It is also clear from the module that the law states that “anyone can administer Naloxone for the purposes of saving a life. If Naloxone is available at your service, then, in the event of a suspected opiate overdose, as long as you understand and are comfortable doing so, you could administer Naloxone. If you have received training, then you should administer Naloxone". Information about further training is also included.

ii. Additional optional training available to staff includes:
• Motivational interviewing
• Strengths-based practice toolkit
• Strengths-based approach to client work – an introduction
• Coaching with clients
• Person-centred support
• Emotional first aid
• Trauma-informed care
• Drug and Alcohol awareness (both face-to-face and e-learning)
• Overdose prevention and Naloxone (both face-to-face and e-learning)
• Supporting clients with Opioid substitute prescriptions (e-learning)
• Alcohol impact session (face-to-face)
• Drugs and the Law (webinar)
• Working with opiate users (face-to-face)
• Unpicking dual diagnosis (webinar)
• Women and substance use (face-to-face)

Compliance Monitoring:
27. Within St Mungo’s we have an ongoing compliance monitoring process called ‘Solid Foundations’. Solid Foundations includes certain indicators which are considered ‘non- negotiable’ to ensure clients and staff are safe and supported; provides assurance to regulators, commissioners and funders; and ensures we are efficient and that we achieve our aims and objectives. We have re-launched this project from January 2025, with the ‘non-negotiables’ to include staff induction and all mandatory training, including first aid training.

28. Managers can check their team’s compliance with the non-negotiables, which includes mandatory training via live Solid Foundation reports, and can address any areas of non- compliance in support and supervision meetings with their staff members (which take place every 4–8 weeks).

29. Service Heads receive weekly automatic reports on their region’s Solid Foundations compliance. These reports help them address gaps, such as discussing issues with Service Managers or raising them in supervision sessions.

30. From February 2025 our Senior Leadership Team will review the Solid Foundations report monthly and develop an ongoing action plan to address any gaps.

31. We use an Induction Checklist for new staff that must be completed within the first six months of employment. This checklist includes mandatory training requirements, details on how to access training, and information on key policies and procedures, ensuring staff know where to find resources when needed. Additional training opportunities are also highlighted.

32. The Learning and Development Team reviews training provision and attendance weekly. As courses fill up, they schedule additional training sessions. They monitor attendance by booking initial dates, tracking uptake, and adding new sessions to ensure staff can book training within their first six months. Their aim is to maintain a rolling three-month availability of courses.

Matters of concern in the PFD Report
33. I have carefully reviewed the PFD Report and have noted in particular that during the course of the inquest, the evidence revealed matters giving rise to your concern that, unless addressed by further action, you believe there is a risk that future deaths will occur. These concerns have been taken seriously and discussed extensively among relevant teams within St Mungo’s. On behalf of St Mungo’s, please find my response to your concerns below:

34. Concern 1: “I heard evidence at the inquest that the night concierge who found Ms Atshiki had not had any first aid training from St Mungo’s. He said that he had undergone first aid training elsewhere in the past, but he did not know whether the hostel had a defibrillator. It did not.”

Response:

i. Immediate Action: Where a defibrillator is available at a service, we will instruct Service Managers to direct staff to the relevant guidance. This information will also be added to our First Aid Policy and Procedure.

ii. Short to Medium-term Action: The Learning and Development team and the Safety and Quality Assurance team will continue reviewing compliance with first aid training on a quarterly basis. They will ensure interventions to improve compliance are regularly assessed and will agree on actions if compliance needs improving.

We are updating our First Aid Procedure to include clear guidance on First Aid at Work and Emergency First Aid at Work qualification criteria, and to stipulate that only where a staff member is confident in delivering First Aid (including the use of defibrillators and delivery of CPR) in line with such criteria, will a previously obtained certificate prior to employment at St Mungo’s be considered and accepted.

We will conduct a review on our “Responding to Emergencies” mandatory e-learning to ensure that it clearly sets out our approach and what we expect from staff in an emergency situation. This review will be completed by June 2025.

Whilst it is my understanding that there is no legal requirement for housing associations to provide defibrillators, we will review the potential for expanding our access to defibrillators in key locations, particularly in 24-hour hostels where the risk of health emergencies is higher. This review will include where defibrillators are already located in our services, the criteria for a service obtaining a defibrillator, taking up offers of free defibrillators from Local Authorities where available, and considering whether to purchase them, where not. This review will be completed by May 2025.

35. Concern 2: “Whilst not relevant in this case, I was told that the hostel does stock Naloxone (used in the emergency treatment of opiate/opioid toxicity), but that the night concierge is not trained in its use.” Response:
i. Immediate action: We understand that the night concierge may have not received training in using Naloxone, which we accept may affect how a person responds in the case of an overdose. The Service Manager at Endell Street is arranging for the staff team to refresh their Naloxone training. Training is available as an on-line video recommended by the St Mungo’s Complex Needs Team that staff can watch. However, whilst we strongly encourage staff to use Naloxone in overdose situations, we do not make this mandatory. We accept that not all our staff (who are non-clinical and recruited to provide housing-related support) would feel comfortable or confident in administering an injection.

In addition to the abovementioned training and guidance that we already have in place regarding the administration of Naloxone, our Complex Needs Team will develop a short guidance document for services to keep accessible within services. This document will provide straightforward guidance on what to do in the event of an overdose, including administering Naloxone. Service Managers will ensure that all staff know where this document is located.

ii. Short to Medium-term action: The Service Manager will ensure that regular Naloxone training is provided to all new staff, as well as refresher training either by the local drug

team or by attending the training provided by our Complex Needs Team. Organisationally, we will provide targeted communication over the next 6 months to encourage all managers to ensure that staff in first-stage hostels, including night staff, are trained on how to administer Naloxone and have regular refresher training in place.

As noted above, key policies are highlighted for client services within our Induction Checklist. We are adding the St Mungo’s Drugs Policy and Procedure and Drug Awareness training to the list of key policies and training to be completed by client services staff as part of the Induction Checklist.

We will conduct a review to determine whether it would be appropriate to add Overdose Prevention and Naloxone Training to our mandatory training list for first-stage hostels, where there is a higher prevalence of clients using substances. This review will be completed by October 2025.

36. Concern 3: “The evidence at inquest was that there are only ever two members of staff working at the hostel at night, of which the night concierge is one. After Ms Atshiki’s discovery, the night concierge stayed with her as she lay across the stairs, while the other member of staff stayed by the front door to open it when the ambulance service arrived. Nobody at the hostel attempted to perform cardiopulmonary resuscitation on Ms Atshiki.

There is no evidence that if CPR had been performed it would have changed the outcome for Ms Atshiki. However, in another situation it might. And in another situation, it might be the second member of staff who falls ill. That would only leave the night concierge to attempt resuscitation.”

Response: In terms of staffing levels, it should be noted that we, St Mungo’s, develop and review our staffing models within each of our service contracts at the start and before any extension of a contract. In many of our high support services, we have a minimum of two staff members working at night, who undertake waking night shifts (on site and awake at all times), and who

support the safe running of the service. We always ensure that our proposed staffing model will allow the service to be run safely, before bidding, accepting or delivering any service contract. However, it also important to note that due to the nature of the financial environment within which we are commissioned, and the significant financial pressures that Local Authorities who often commission us face, there are significant and growing pressures to meet financial envelopes dictated by those commissioning our services. This sometimes means that in services where it might be preferable, but not necessarily essential, to have a third staff member on shift in the rota, we are unable to do so due to the financial constraints of the contract.

We use tried and tested service models to meet the needs of the client group and the requirements of the service and building(s). These models are reviewed throughout the life cycle of the contract and at the point of contract renewal or negotiation to ensure they are still meeting the requirements of the service. Our staffing models are co-designed by multiple departments across St Mungo’s, including Client Services, Finance, HR, Business Development and Property Services, before being signed off by our Executive Directors.

In terms of concerns around the use of CPR:

i. Immediate action: We understand that the outcome in this case would not have been changed by CPR, but in other cases timely CPR could impact the outcome.

In addition to the immediate actions related to First Aid Training (noted under Concern 1), as detailed above, we have relaunched our Solid Foundations process as of January 2025. First Aid training will be tracked in Solid Foundations to increase visibility and improve reporting. Responding to Emergencies e-learning has also been added to Solid Foundations for better compliance tracking and reporting. As noted above, First Aid Training and the Responding to Emergencies e-learning covers the provision of CPR.

ii. Short to medium-term action: In addition to the actions related to First Aid Training (noted under Concern 1), the Service Manager at Endell Street will complete a review of training completion for all staff, including night staff, and will ensure that all staff have completed the Responding to Emergencies e-learning. The Service Manager will also ensure that staff

complete the annual refresher, so that staff are confident in their ability to perform CPR in any situation.

We are also updating our First Aid Policy and Procedure to further reflect and reiterate the requirement for First Aiders and Emergency First Aiders to provide CPR when necessary.

Conclusion:
40. On behalf of St Mungo’s, I am grateful for your recommendations that will enable us to be as well-equipped as possible to respond to similar incidents in the future.

41. I hope that this response assists you in understanding St Mungo’s role as a charity and the action it has and will continue to take in relation to the safety and wellbeing of its clients.

42. Should you require any further information, please do not hesitate to contact me.