Dear Mr Osborne

Re: Regulation 28 report to prevent further deaths

I am the Independent Chair of Milton Keynes Safeguarding Board and am writing following your correspondence of 22nd May 2017 with , Milton Keynes Council Chief Executive in relation to Kevin George Morgan. Thank you for returning my call as I always (as a totally independent chair) prefer (wherever possible) to deal directly with senior public sector leaders across the Milton Keynes system, whatever their role.

It is nearly 12 months since you wrote to , and the response should have come much sooner. I will be considering why it took so long as part of the actions I have decided to take, but believe it to be a consequence of a major restructure, major staff shortages and a lack of rigour in the tracking systems that were in place until relatively recently. Whatever the cause it should not have taken so long however and I apologise for the delay.

wrote back to you on 12th July 2017 indicating that in response to the Regulation 28 report a referral was made to the Milton Keynes Safeguarding Board for a Safeguarding Adults Review (SAR) to be conducted under Section 44 of the Care Act 2014. That referral was made and the process of considering the case began. I received a recommendation from the Adults Case Review Panel recently but delayed making a decision until I had thoroughly examined all of the facts, taken advice and weighed it up carefully.

My decision is that the case does not meet the criteria for a Safeguarding Adult Review, but as I share many of the concerns you expressed in your Regulation 28 report, I have commissioned another more flexible but no less rigorous form of review called a learning review in order to establish what can be learnt from the case to improve practice and reduce the likelihood of similar cases occurring. I am happy to send you my full decision should you wish to see it, but have set out below the decision and the commission for a learning review for your information.

My decision is as follows: The case does not meet the criteria for conducting a Safeguarding Adult Review as set out in the Care Act 2014 S44 (1) and S44 (2). The rationale for this conclusion is set out in the section below.

I have decided however that a multi-agency learning review, chaired by a relevant professional from one of the agencies who has no links to the case, should be undertaken, and that the review should involve:

MKSB, Saxon Court, 502 Avebury Boulevard, Milton Keynes MK9 3HS Email: mkscb@milton-keynes.gov.uk/ tel: 01908 254373

 Mr M’s mother and other family members of her choice (through the opportunity to meet and speak to the review chair and a review group member)  A practitioner event involving all relevant practitioners in the NHS, the Council, the Police and the Voluntary sector  An analysis of agency case reports  In depth consideration of the areas for concern 1-6 in the Regulation 28 report and any other areas identified by Mr M’s family, identified in agency reports or identified at the learning event,  A Signs of Safety approach to the learning process (what went well, what did not go so well, what does that tell us, what will we do as a result)  A short report making recommendations for practice improvements to the MKSB Board (copied to the MKC Chief Executive) and suggesting effective ways to disseminate the learning to the multi-agency workforce  A meeting with Mr M’s mother should she wish, to hear what has been learnt and what will change as a result of the review. The terms of reference for the learning review should be drafted by the panel and signed off by me.

The review should be undertaken as swiftly as possible given that information about the case has already been collated. I anticipate receiving the report at the September 2018 Board meeting.

I will be reporting to the Chief Executive and to Mr M’s mother on the conclusion of the review process.

I am of course very happy to discuss further my decision should you feel the need to do so.

I understand that there are a number of other cases that you have expressed concerns about. I discussed this with the MK Safeguarding Board Members and we are delighted you are happy to accept our invitation for you to meet with the Board to discuss areas of common concern, and how we could more effectively address those concerns in the future. We will, I am sure, find it extremely constructive to meet with you.