Rebecca Hayward
PFD Report
All Responded
Ref: 2022-0321
All 1 response received
· Deadline: 9 Dec 2022
Sent To
Response Status
Responses
1 of 1
56-Day Deadline
9 Dec 2022
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
(1) Assessments of persons with severe and multiple disadvantage are undertaken by persons with little or no experience or specialist training in homelessness and substance misuse, resulting in inaccurate assessment and plans; (2) Where a person is about to move to a different type of accommodation, Care Act assessments are only extended to include consideration of the individual’s changed care needs in their new environment if the early assessment work identifies eligible care needs in their current circumstances, with the social care provision subsequently being dependant on a re-referral and where such re-referrals are resisted; Other areas of concern existed regarding other issues but plans were in place to address these areas and so I did not have ongoing concerns of a risk of future deaths.
Responses
Nottingham City Council has developed an overarching action plan, to be reviewed monthly, which will incorporate revised policies and training programmes to address the coroner's concerns regarding assessments.
AI summary
View full response
Dear Mr Clow,
RE: Regulation 28 – Report to Prevent Future Deaths
I am writing to provide you with a response to the above Regulation 28 report, dated 13 October 2022, following the unfortunate death of Ms Rebecca Hayward.
The matters of concern have been reviewed and addressed by the Nottingham City Council Adult Social Care Senior Leadership Team, and Principal Social Workers. We have developed an overarching action plan which provides a comprehensive response to these matters. The plan will be reviewed on a monthly basis, and will be governed by the Senior Leadership Team. Progression of the plan will be evidenced through review of all reports and revised policies, data reporting and qualitative measures which will be incorporated into all revised policies and training programmes.
The other areas of concern identified in the Case and Quality Assurance Review submitted by Nottingham City Council in evidence to assist the Inquest will adhere to the same governance arrangements as noted above.
I hope that the actions and governance arrangements provide you with assurance of Nottingham City Councils commitment to addressing the issues raised both by yourself, and through the Adult Social Care Case and Quality Assurance Review. Please contact me should you require any further information or updates.
RE: Regulation 28 – Report to Prevent Future Deaths
I am writing to provide you with a response to the above Regulation 28 report, dated 13 October 2022, following the unfortunate death of Ms Rebecca Hayward.
The matters of concern have been reviewed and addressed by the Nottingham City Council Adult Social Care Senior Leadership Team, and Principal Social Workers. We have developed an overarching action plan which provides a comprehensive response to these matters. The plan will be reviewed on a monthly basis, and will be governed by the Senior Leadership Team. Progression of the plan will be evidenced through review of all reports and revised policies, data reporting and qualitative measures which will be incorporated into all revised policies and training programmes.
The other areas of concern identified in the Case and Quality Assurance Review submitted by Nottingham City Council in evidence to assist the Inquest will adhere to the same governance arrangements as noted above.
I hope that the actions and governance arrangements provide you with assurance of Nottingham City Councils commitment to addressing the issues raised both by yourself, and through the Adult Social Care Case and Quality Assurance Review. Please contact me should you require any further information or updates.
Report Sections
Investigation and Inquest
On 12 January 2022 an inquest was formally opened into the death of Rebecca Hayward who died on 13 August 2021. The investigation concluded at the end of the inquest on 13 October 2022. The conclusion of the inquest was the short form conclusion that Rebecca Hayward’s death was alcohol and drug related.
Circumstances of the Death
Rebecca Hayward had a history of substance addiction throughout her adult life. She managed to achieve abstinence from alcohol and drugs from March 2020 through to March 2021. Ms Hayward’s recovery from addiction was vulnerable, however, and she was assessed by her substance misuse worker to be unable to avoid relapse if she were to be homeless and accommodated in hostel accommodation. In the weeks leading up to Ms Hayward’s discharge from the care home, her substance misuse worker repeatedly and consistently reminded the professionals involved in Ms Hayward’s care of the need to avoid Ms Hayward being discharged to a hostel and of her view that a discharge to a hostel would result in Ms Hayward’s death from substance misuse. Ms Hayward became homeless on discharge from her care placement on 31 March 2021 whereupon she was accommodated in a hotel. She was provided with hostel accommodation on 5 May 2021. As had been predicted, this led to a relapse into alcohol and, latterly, substance misuse with catastrophic consequences for Ms
Hayward’s health and personal safety. On 13 August 2021 Ms Hayward was found deceased at someone else’s property following a period of alcohol and substance misuse. Ms Hayward’s death was a predictable consequence of the effect upon her of becoming homeless on 31 March 2021.
Hayward’s health and personal safety. On 13 August 2021 Ms Hayward was found deceased at someone else’s property following a period of alcohol and substance misuse. Ms Hayward’s death was a predictable consequence of the effect upon her of becoming homeless on 31 March 2021.
Copies Sent To
set out above
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Improve perinatal mortality recording
Morecambe Bay Investigation
Inaccurate and inaccessible patient records
Detainee Capture and Condition Records
Al-Sweady Inquiry
Inaccurate and inaccessible patient records
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.