Dear Sir

Inquest into the death of Omar Ahmed – 15 July 2024 Prevention of Future Deaths Report Ref:

We write in response to the Prevention of Future Death Report (‘the PFD Report’) issued at the conclusion of the inquest hearing in accordance with Regulation 28 of the Coroners (Investigations) Regulations 2013.

We are committed to providing the highest standards of safety and care and wish to ensure that any lessons to be learnt from the circumstances of Mr Ahmed’s tragic death are identified and implemented as necessary within our agency. Alongside our engagement with the coroner’s investigation, we have conducted our own internal review process, updated our policies, commenced the implementation of a full programme of updated communication, consultation and training, and proactively liaised with the East London Foundation NHS Trust (‘the Trust’) and the London Borough of Newham (‘the Local Authority’).

We have provided further details concerning this process below, including the time frames for elements of this process which are in progress.

Our review process

After being informed of Mr Ahmed’s death by the Local Authority on 22 December 2023, we conducted a thorough Serious Incident Review (‘SI Review Report’), with a focus on the care provided in cases involving a history or risk of self-neglect. This involved a comprehensive review of our policies and procedures and preparation of a detailed report focussing upon protecting and supporting our service users. The SI Review Report sets out the steps we are taking to enhance our safeguarding practices and provides a framework for continuous improvement.

In addition to updating and, where necessary amending our policies, we commenced an eight- week implementation programme on 5 August 2024. A summary of this programme setting out the topics of training, appears in Appendix A.

A Brighter Tomorrow… A: 3-9 Balaam Street, London E13 8EB T: 02086 112 771 E: info@sunlightgroup.co.uk W: www.sunlightgroup.co.uk Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. Registered Office: 3-9 Balaam Street, London, E13 8EB

At the conclusion of the programme, we will hold review meetings to discuss the implementation programme, including challenges and successes, as well as developing further areas of continuous improvement.

The implementation programme of our revised policies and training is being led and overseen by a new internal Governance Team led by our Director of Nursing (Advanced Practitioner / Registered Mental Health Nurse) and including our Director for Quality, Trusted Assessor, Care Champion, Nominated Individual and Registered Manager. We have engaged an independent Registered Mental Health Nurse to provide external governance and accountability. This programme is being properly resourced and supported by the most senior managers and leaders within our service.

Response to the coroner’s ‘matters of concern’

Our Internal Governance Team has carefully considered the ‘matters of concerns’ set out in the PFD report relevant to the service provided. With this in mind, we have set out our response with respect to the first and third matters highlighted by the coroner which are relevant to the care we provided.

1. Poor standards of communication

The coroner highlighted the following concern in the PFD Report:

“Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed’s living conditions and health.”

Mr Ahmed was under the care of our agency from 31 October 2023 and was admitted to hospital on 15 November 2023 before he sadly passed away on 21 November 2023. We submitted a detailed chronology of our care notes and communications with the Local Authority and GP for the purposes of the inquest hearing. Our Duty Manager contacted the Local Authority on 10 November and again on 12 November 2023 regarding concerns about the lack of basic supplies and issues with financial decision-making. On 13 November 2023, the Local Authority responded, confirming that the duty social worker had made enquiries with Mr Ahmed’s next of kin. They also invited follow-up communication in the coming days and weeks.

Our own review

We have scrutinised how we would approach circumstances in the future where a client is making poor decisions with respect to their nutrition, cleaning and personal care, as well as their finances. In circumstances where clients have capacity, to enable appropriate action to

A Brighter Tomorrow… A: 3-9 Balaam Street, London E13 8EB T: 02086 112 771 E: info@sunlightgroup.co.uk W: www.sunlightgroup.co.uk Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. Registered Office: 3-9 Balaam Street, London, E13 8EB

be taken in conjunction with social work and health services, the key issues to be addressed are early notification internally, escalation to the Local Authority and NHS Trust as necessary, and proactive follow up.

This issue was identified and addressed in our SI Review Report in which we have confirmed our revised standard notification and response protocols with the Admissions Policy as follows:

1. Continuing to provide detailed and factual reports of safeguarding concerns to local authorities within 24 hours;
2. Expect a response and action from local authorities within 48 working hours;
3. Actively monitor the situation and follow up to ensure concerns are addressed effectively.

This is supplemented by updated notification and monitoring procedures within our suite of relevant policies:

• Self-Neglect Policy
• Home Environment Safety Policy
• Nutrition and Hydration Policy
• Infection Control Policy
• Admissions Policy
• Handover Policy
• Environmental Safety Policy
• Care Plan Adherence Policy
• Risk Management Policy
• Decision Making and Consent Policy
• Engagement and Participation Policy
• Multi-Disciplinary Team Collaboration Policy
• Medication Management Policy
• Safeguarding Policy
• Admissions Policy
• Handover Policy

Multi-agency liaison and plan

In addition, we attended a multi-agency discussion with the Local Authority and NHS Trust to discuss lessons learnt on 23 July 2024 and arranged a follow up on 4 September 2024. At the second meeting, the following actions were agreed to be undertaken within a twelve week time frame:

• Communication and Escalation Strategies: The team will implement new strategies to improve communication and timely escalation of safeguarding issues across teams.

A Brighter Tomorrow… A: 3-9 Balaam Street, London E13 8EB T: 02086 112 771 E: info@sunlightgroup.co.uk W: www.sunlightgroup.co.uk Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. Registered Office: 3-9 Balaam Street, London, E13 8EB

• Development of Risk Assessment Tool: Newham Council and Sunlight Care will collaborate on the development of a risk assessment tool to identify and protect vulnerable individuals.

• Training and Process Improvements: Sunlight Care staff will receive additional training on safeguarding protocols, communication, and the new risk assessment processes.

A Serious Adults Review Board Meeting has been arranged to take place on 24 September
2024.

In view of the above, we are confident that our revised policies and procedures are robust and staff will proactively escalate similar concerns internally and our managers will proactively monitor concerns raised with the Local Authority.

2. Lack of challenge to poor decision-making

The coroner highlighted the following concern in the PFD Report:

“Mr Ahmed’s poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home.

Similarly, Mr Ahmed’s unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition -hypothermia, remained unchallenged at the time of his death.

Domiciliary carers capitulated to Mr Ahmed’s express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.”

An element of Mr Ahmed’s Care and Support Plan was to facilitate community engagement and social interaction, which was important to Mr Ahmed. In circumstances where there is evidence of self-neglect and a client may not be making appropriate decisions concerning eating, cleaning, hearing and personal care, it is clear that this must be addressed by those involved in the client’s care. As the coroner is aware, Mr Ahmed had capacity and was therefore able to make his own decisions. This creates significant challenges for care providers, which are reliant upon working alongside the statutory agencies to make any formal interventions necessary.

Within the existing framework, we have considered what additional steps could be taken in the future. We have reviewed and updated our protocols to ensure that care providers are well-supported in addressing situations where clients with capacity may be making decisions that appear to be against their best interests, such as in cases of self-neglect. Specifically:

A Brighter Tomorrow… A: 3-9 Balaam Street, London E13 8EB T: 02086 112 771 E: info@sunlightgroup.co.uk W: www.sunlightgroup.co.uk Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. Registered Office: 3-9 Balaam Street, London, E13 8EB

1. As set out above, we have revised our own policies and training to reinforce the importance of clearly and swiftly communicating issues of concern internally to enable the concerns to be properly assessed and escalated to the Local Authority and NHS as appropriate;

2. As set out above, we are implementing more robust inter-agency collaboration and clearer guidelines for escalation pathways. This will involve enhanced communication with social workers, GPs, and mental health teams to provide timely and appropriate interventions while respecting the client's autonomy;

3. We are introducing regular multidisciplinary reviews for cases involving self-neglect, allowing for a more holistic approach to care that includes input from a range of professionals. This will help ensure that all aspects of the client's well-being—physical, mental, and social—are considered in decision-making processes;

4. The training programme referred to above includes additional training focused on identifying early signs of self-neglect, understanding legal frameworks such as the Mental Capacity Act, and how to engage effectively with clients who may resist care or intervention. This proactive approach aims to minimize risks while upholding the individual's rights and dignity.

We also highlight the relevance and importance of the ‘Liberty Protection Safeguards’ (‘LPS’) framework which was to have been introduced to replace the ‘Deprivation of Liberty Safeguards’ (‘DoLs’) framework. One relevant difference would have been the availability of the LPS framework to those living in their own home, as DoLs orders are only available to those in care homes and hospitals. We understand that the LPS framework provides a simpler and clearer framework to seek authorisation for an order to facilitate care and health treatment where needed, including those in their own home.

The Local Authority has informed us that the LPS framework will no longer be implemented. As a result, they will continue to rely on the existing DoLs framework, which does not apply to individuals living at home. We understand that the new LPS framework would have provided those involved in Mr Ahmed’s care with the opportunity for assessment of his ability to make appropriate decisions in his own best interests. This is a challenge we trust will be remedied within new legislation.

A Brighter Tomorrow… A: 3-9 Balaam Street, London E13 8EB T: 02086 112 771 E: info@sunlightgroup.co.uk W: www.sunlightgroup.co.uk Vista Care Solutions Ltd trading as Sunlight Care Newham. Registered in England. Company No: 11353031. Registered Office: 3-9 Balaam Street, London, E13 8EB

Finally, we wish to reiterate our deepest sympathies for Mr Ahmed’s family. We emphasise our desire to ensure that any changes to our service are identified and implemented to ensure that similar issues with clients in future are dealt with as quickly and effectively as possible.

Dear Mr Irvine Re: Regulation 28 Report concerning Omar Ahmed Response from the London Borough of Newham Thank you for sharing the conclusion of your Inquest into Mr Ahmed’s death, and the subsequent Regulation 28 Report. May I start by expressing my sincere regret and disappointment to learn of the circumstances surrounding Mr Ahmed’s passing. On behalf of the Council I wish to place on record our deepest condolences to his family and friends and all those that knew him. We fully acknowledge the findings from the Inquest and are firmly committed to putting actions in place to address the concerns raised in the Prevention of Future Deaths report to ensure that a similar situation is not repeated. A core group of Senior Officers from within the department have reviewed Mrs Ahmed’s case in detail and have developed a series of direct actions in response. The following actions have been agreed Action: By who: By when: 1 Immediate Safeguarding Adults Review (SAR) Referral for presentation at the next SAR subcommittee (Director of Quality Assurance, Safeguarding and Workforce Development) and ( North West Neighbourhood Team) Completed on 09/08/24 Mr Ahmed is on the agenda for the SAR subcommittee on 24/09/24 2 A meeting with the Sunlight Care to ensure that any risks to residents they provide care and support to is mitigated. This will be achieved by the following actions Strategic Safeguarding and the Quality Assurance and Meeting held on 17/07/24 although the QIP is ongoing

 A quality improvement plan (QIP) is in place  Enhanced monitoring of all residents Sunlight Care provide care and support to is in place  Welfare checks of all residents Sunlight Care provide care and support to who live alone has taken place Commissioning Team 3 Enhanced monitoring of the provider will take place at the 6 weekly provider risk management board (PRAMB). The board is a multi-agency partnership which includes social care, health and the CQC PRAMB Partnership Ongoing 4 Adult Social Care will lead on the development of an escalation procedure which will enable partners to flag cases where there is concern about a high level of unmitigated risk or differences of opinion about the level of risk. This procedure will involve reviews of the following protocols:
1) The no reply protocol
2) The refusal of care protocol Strategic Safeguarding/ Workforce Development/Quality Assurance and Commissioning Team March 2025 5 The issues regarding the safeguarding activity in this case will be addressed by reflective sessions which cover the following areas  The London Borough of Newham’s decision making/actions in relation to safeguarding concerns  Multi-agency working  The application of Making Safeguarding Personal These sessions will be available for all operational staff in Adult Social Care. Content will also be available to selected staff from Sunlight Care and staff from ELFT Workforce Development and Strategic Safeguarding 30/11/24 6 The issues regarding risk assessment and risk management will be addressed by a reflective session which covers the following areas:  Information sharing  Joint decision making  Co-ordinated intervention  Thresholds for home visits/joint home visits  Thresholds for urgent reviews Workforce Development and Strategic Safeguarding 30/12/24

 Executive capacity and decision making  Risks associated with social isolation  Non adherence with care plans These sessions will be available for all operational staff in Adult Social Care. Content will also be available to selected staff from Sunlight Care and staff from ELFT 7 Produce a ‘7 minute briefing on the development of risk management plans. This will be distributed across all Adults and Health staff groups and presented at the provider forum Workforce Development and Strategic Safeguarding 30/12/2024 8 Produce a ‘7 minute briefing with a focus on the issue of non-adherence with care plans. This will be distributed across all Adults and Health staff groups and presented at the provider forum Workforce Development and Strategic Safeguarding 30/01/24 9 Adult Social Care will lead on a joint learning event involving staff from ASC, staff from Sunlight Care and staff from ELFT. The learning event will focus on the following issues:  Professional and clinical curiosity  Working with resistance and non- adherence  Executive capacity and decision making Workforce Development and Strategic Safeguarding 20/12/2024 10 Review of the Safeguarding Adults Operational Procedure Strategic Safeguarding 30/11/24 11 Training on how to implement lessons of inquest hearings to improve service delivery to vulnerable persons within our community Legal Department 06/09/24 Governance and Oversight The following people have been sighted on the action plan: 
-Corporate 
-Director of Quality Assurance, Safeguarding and Workforce Development 
-Head of Service - Older People & Disability, Operations 
-Head of Service - Older People & Disability, Operations

All elements of the plan are linked to specific teams with accountability for their delivery. Oversight of the action plan is being held by the Strategic Safeguarding team who will monitor progress against the stated timescales and then report back to our Directorate Management Team. We also recognise that the overall plan will need to remain agile and be adapted if further information comes to light, particularly if Mr Ahmed’s case is the subject of a SAR. Thank you again for raising this matter with us. I hope this response gives adequate assurance on the actions we have taken on the improvements required. Please do not hesitate to come back to me if you require further information or updates.

Dear Graeme,

Thank you for the Regulation 28 report of 7 July, sent to the Department of Health and Social Care (DHSC), about the death of Mr Omar Abdi Ahmed. I am replying as the Minister with responsibility for adult social care.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Ahmed’s death; I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over:

1. Poor standards of communication between the domiciliary care company, Local Authority (LA) and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed's living conditions and health.
2. An under-resourced and demoralised district nursing team that lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment.
3. An unwillingness by domiciliary carers to challenge Mr Ahmed's poor decision-making in how he budgeted, leading to a lack of nutritious food and cleaning materials, and a reluctance to switch on his central heating, the latter being a contributary factor in his death from hypothermia.

In preparing this response, departmental officials have made enquiries with NHS England (NHSE) and the independent chair of Newham Safeguarding Adults Board (SAB).

In response to your first concern, section 6(7) of the Care Act 2014 states LAs must co- operate with relevant partners, such as domiciliary care companies and NHS trusts, and those partners must co-operate with the LA in the exercise of their functions to protect adults.

The Care Act 2014 requires each LA to set up a SAB in its area. SABs are required to carry out a Safeguarding Adult Review (SAR) where an adult has died, and the SAB knows or

suspects the death resulted from abuse or neglect (whether or not they knew this at the time of death). The SAR should identify the lessons to be learnt from the adult’s case and apply those lessons to future cases. To understand the communication failures related to your first concern, DHSC contacted the independent chair of Newham SAB asking whether they are considering doing a SAR. The chair shared they are collecting information on the case before deciding what to do next.

In response to your second concern, NHSE shared details of their Community Nursing Safer Staffing Tool to support organisations to triangulate their nursing staffing numbers. This will create availability for more nursing staff to meet increasing patient demand. NHSE are also looking to scope and commission future educational support for district nursing, and within the Long-Term Workforce Plan there is an ambition to increase training places for district nurses by 41%.

NHSE also reached out to the East London Foundations NHS Trust directly – my officials await their response and will consider how to learn from any information that is relayed. To note the Trust, Council, and private care provider are also recipients of this PFD and will be developing their own responses, which officials expect to be sighted on in due course.

Your third concern was regarding Mr Ahmed’s carers’ failure to challenge his poor decision- making. I infer from this that you feel Mr Ahmed may have lacked the relevant mental capacity and that you feel professionals responsible for his care should have assessed his mental capacity. I note professionals should start by presuming capacity and that poor decision-making does not necessarily equate to a lack of mental capacity to make those decisions. These are two of the five principles under the Mental Capacity Act (MCA) which is strongly supported by experts by experience. However, I am aware these principles have been used to justify a lack of clinical curiosity from health and social care workers in several cases. I can say that using the presumption of capacity and the freedom to make unwise decisions to avoid challenging poor decision-making is not in line with the MCA guidance or case law. Government is clear that professionals applying the MCA are expected to keep up to date with the guidance and not misuse the principles within the Act.

While employers in the health and care sector have ultimate responsibility to satisfy themselves regarding the skills and competence of their staff, DHSC also provides support. On January 10th, 2024, the DHSC published the first part of the Care Workforce Pathway, a new national career framework for the adult social care sector. This pathway defines knowledge, skills, values, and behaviours of those working in, or wanting to work in adult social care, should have. Although not mandatory, it is designed to improve how providers can support and develop their workforce. The Pathway is being developed to work in conjunction with existing standards and competency frameworks. The Care Quality Commission (CQC) will look at a provider's approach to staff induction, support and training using CQC's key lines of enquiry.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Dear Sir,

RE: Regulation 28 Response for the late Mr Omar Abdi Ahmed

1. This is a formal response to your Regulation 28 Report (the ‘Report’) issued on 22 July 2024 where you set out concerns relating to the care of late Omar Abdi Ahmed whilst under East London NHS Foundation Trust’s (the ‘Trust’s’) care.

2. I understand that at Mr Ahmed’s inquest, you heard evidence from the 72 hour report author outlining the learning that has taken place since his death. I understand that you remained concerned about the risk of future deaths in relation to the following areas:

2.1. Poor standards of communication between the domiciliary care company, the local authority and NHS trust resulted in a failure to identify the deterioration in Mr Ahmed's living conditions and health.

2.2. Evidence heard in the inquest suggested an under-resourced and demoralised district nursing team lacked the clinical curiosity to predict the harm that would befall Mr Ahmed should he be allowed to disengage from treatment.

Chief Executive:

Chair:

2.3. Mr Ahmed's poor decision-making in how he budgeted was never challenged, this led to a lack of nutritious food and cleaning materials in his home. Similarly, Mr Ahmed's unwillingness to turn on his central heating, a contributory factor in the development of his fatal condition hypothermia, remained unchallenged at the time of his death. Domiciliary carers capitulated to Mr Ahmed's express wishes that they ought not assist him with cleaning, personal care or meals instead, state-funded care hours were utilised to assist Mr Ahmed in attending his local pub and café.

3. I wish to assure you and the family of Mr Ahmed that the Trust reviewed the issues highlighted in the Report and has taken the following action.

RESPONSE

Standards of communication

4. The Trust is unable to comment on behalf of London Borough of Newham (‘LBN’) or the domiciliary care company. However, it can confirm that LBN and the Trust have systems in place which facilitate joint working to improve care for service users under both services.

5. The Trust raised a Safeguarding Adult concern to LBN in relation to Mr Ahmed, however it was not followed up until after his death by LBN. LBN have conveyed that they are struggling with capacity at the moment.

6. In light of this, all Trust staff have been reminded (during individual supervision) of the Trust’s internal escalation pathway. They are expected to follow this pathway when there are concerns about the safeguarding process between public bodies. It is a tool to support staff in recognising their responsibilities and ensuring they follow up all safeguarding referrals made, and escalate any barriers identified without delay. It also ensures that the relevant senior management is aware of concerns. It has been made clear to Trust staff that they should not wait for the monthly safeguarding forum to escalate any barriers or problems related to safeguarding process initiated by them.

Chief Executive:

Chair:

7. Since the receipt of the Report, two meetings have taken place between the Trust’s Director of Nursing, Community Health Service’s Medical Director and LBN’s Senior Safeguarding Adviser and Interim Service Manager for Access to Adult Social Care and hospital discharge. It was explored how to further improve escalation and communication between the services in relation to high risk service groups. The outcome of both of these meetings is that both the Trust and LBN’s teams will meet in October 2024 to review the current pathways and organisational interface to ensure better communication relating to patient care.

8. Communication between domically care providers and Community Health Newham (the Trust) is done on an individual service user basis. The system is designed so that a General Practitioner is the gate keeper of care and manages and coordinates communication between the public bodies. That said, if a high risk service user presents as a concern to Trust staff members, they are proactive and will arrange a professionals meeting for all agencies involved. We plan to review this process with all staff over the next two months to ensure that they are aware of their responsibilities and understand the importance of acting on concerns.

District nursing team lacked clinical curiosity as a consequence of resourcing and demoralisation

9. It was concerning to hear that clinical staff members in charge of wound dressing were under-resourced and demoralised resulting in a lack of clinical curiosity towards Mr Ahmed.

10. Further context may assist in how that impression was reached. Traditionally, simple wound care services were provided by multiple providers across Newham. However, over time the wound dressing clinic at East Ham Care Centre (the ‘dressing clinic’) became the default provider for all wound dressing services. This created significant pressures on staff.

11. In order to reduce these demands, in September 2023, the Integrated Care Board led an improvement program to transfer the management of simple wounds to General Practitioners. This process commenced in April

Chief Executive:

Chair:

2024. Now, only complex wounds are managed by the dressing clinic. Consequently, only secondary and primary care professionals such as General Practitioners, practice nurses, and acute care clinicians (doctors and nurses) can refer complex wounds to the dressing clinic. Simple wounds are managed in GP practices. It is anticipated that this reallocation of care will improve the working conditions for the wound care team.

12. Since the sad death of Mr Ahmed, some further changes were introduced to the dressing clinic. It is now staffed by a substantive band 6 nurse (as opposed to temporary staff) whose clinical and professional line management is provided by senior nursing within the Trust’s Community District Nursing Team. I expect this will improve the accountability of clinical staff on the team as well as allow them to receive more consistent supervision and improve clinical skills and enhance curiosity.

13. On 24 July, a new standard operating procedure was put into place for dressing clinic staff. The key change is that the time slots allocated to attend to service users has increased from 10 minutes to 30 minutes. It is anticipated that the provision of additional time to complete work should improve care planning and allow more meaningful communications with other services as well as improve staff morale.

Poor decision making

The local authority, not the Trust commissioned the domiciliary care providers. Consequently, it is expected that the commissioner and the General Practitioner would manage concerns. However, as outlined in paragraph 8, Trust staff should be proactive when they witness concerns and arrange professionals’ meetings between agencies. This will be reviewed with staff over the next two months.

Conclusion

14. I hope this response provides sufficient reassurances to you and to the family of Mr Ahmed about the additional learning that has taken place at the Trust because of his sad death.

Chief Executive: Chair:
15. I would like to offer my sincere and heart-felt condolences to the family at this difficult time.