Dear Ms Mundy,

IN THE MATTER OF A REGULATION 28 REPORT TO PREVENT FUTURE DEATHS FOLLOWING AN INQUEST INTO THE DEATH OF JEAN MIULLEN

This response is provided to address the concerns raised by your Regulation 28 report dated 12 December 2024 in which you invite me, on behalf of City of Doncaster Council (“the Council”), to consider the following:

(1) The training of staff regarding the importance of recording instances such as falls and escalating the same.

(2) Following up on recommendations for aids and equipment required to ensure a safe home environment for elderly persons such as Mrs Mullen.

(3) The importance of full and accurate record keeping.

I have been able to consider the aforesaid points with reference to the heads of the relevant services and am able to provide the following information by way of reassurance that the Council’s systems of record keeping and communication are robust and effective:

(1) The training of staff regarding the importance of recording instances such as falls and escalating the same:

➢ All of our social care staff undergo specific training as a matter of course on the need for detailed accurate records to be maintained in care settings, including the recording of slips and falls and general health related events.

➢ As a matter of practice, we use the Mosaic electronic recording system to facilitate our record keeping and all social care staff are fully trained and familiar with the processes involved. Pre-populated forms are available for various tasks, including reports, risk assessments and interactions that need

Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU to be recorded and this has the advantage of directing staff to the questions and issues that need to be addressed.

➢ By way of reinforcing this and other aspects of training, front facing social care staff are required to attend one to one supervision sessions on a monthly basis. The purpose of these sessions is to discuss ongoing cases which are specific to that member of staff and to provide the opportunity to raise any issues of concern.

➢ The discussion of matters of concern is not limited to the monthly sessions and social care workers are constantly engaging with each other and sharing experiences and knowledge to solve any problems arising.

➢ The need for detailed accurate records to be maintained in care settings is stamped into the DNA of our social care staff, as well as being a key requirement of CQC, whose jurisdiction we are subject to as care providers. We are well aware of our reporting and recording obligations and are fully compliant with these standards and requirements.

➢ In addition to the measures above, we undertake internal audits on a regular basis to ensure consistency in reporting. Cases are selected on a random basis at the rate of two cases per team per month and the records are scrutinised for discrepancies and any failures to follow up concerns and/or recommendations for referrals etc.

➢ Care packages are provided by independent care providers who are not associated with the Council, but who are subject to regulation by CQC and who are engaged pursuant to contracts that stipulate the care standards to be expected. They are also required to adhere to the same protocol as the Council in respect of record keeping.

➢ The records produced by care providers are subject to internal audits by the Council’s commissioning department on a regular basis in the same way that the Council’s own records are subject to scrutiny.

➢ The care providers also have their own internal auditing processes and would face significant commercial disadvantage if they failed to adhere to the standards expected. In such event they might lose the benefit of any contracts or more significantly, might be held responsible for any safeguarding issues arising, which had not been properly addressed.

➢ It should be noted that carers and social care staff are not qualified to diagnose medical conditions or to make recommendations for aids and equipment. Their role is to raise any perceived concerns and to direct the person in question to the relevant professional for advice, usually an occupational therapist, physiotherapist, or District Nurse. All staff are aware of this process and do not require permission to take such steps.

(2) Following up on recommendations for aids and equipment required to ensure a safe home environment for elderly persons such as Mrs Mullen: where a recommendation has been made for aids and equipment, this will be ordered by the professional making the recommendation. The Council will always follow up any delay in provision and assist in any way possible.

Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU

Since this incident and as part of “lessons learnt” we have set up a “Home First Forum” with a view to providing all domiciliary home care providers information as to when and to whom they should direct any referrals. The first event was held on 30 January 2025 and further events will be held on a quarterly basis.

(3) The importance of full and accurate record keeping: the Council is well aware of the importance of full and accurate record keeping and has robust systems in place to ensure that this is maintained, as set out above.

I consider that it might be useful to make some further points to put Mrs Mullen’s situation into context and to address some of your observations made in respect of the events leading up to her fall.

I understand that Mrs Mullen was admitted to hospital for several days after a fall from her bed (in the context of suffering with a urinary tract infection) and was discharged home on 22 March 2024. Whilst she was in hospital, a needs assessment was carried out by the Council’s STEPS team. This team provides reablement to persons from hospital to home and if care is required, this will be provided by the Council free of charge for 6 weeks.

The STEPS team concluded that Mrs Mullen needed assistance to manage at home and a care package was set up with carers visiting twice a day in the morning and evening. At the same time an assessment was carried out by the NHS occupational therapist, Beverley Hanes, who passed her fit to manage on stairs. Beverley Hanes also visited Mrs Mullen’s home the day before the discharge date and maintained her advice in respect of the stairs. This decision was not within the expertise of the Council’s social care staff but lay within the expertise of the occupational therapist.

Mrs Mullen did not return home until various remedial measures had been taken by her daughter (the owner of her home) including a general clean up and securing pieces of loose carpet. Mrs Mullen then received reablement care for 6 weeks and no concerns were raised during this period about her ability to manage at home.

At the 6 week point a review was undertaken by the Council ( ). It is correct that she did not undertake a stairs assessment. Mrs Mullen had been passed fit to manage on stairs by the occupational therapist and a further assessment was not considered to be necessary. It would not have been within ’s remit to undertake such an assessment in any event. If there had been any concerns about Mrs Mullen’s ability to manage stairs, this would have been referred back to Beverly Hanes for further assessment.

Following this review, Mrs Mullen’s daily care package continued, with additional care being provided on top 3 days per week to assist her with showering. The care provider was Newdon Care.

The Council does not have any record of Patricia Mullen informing social care that the stairs were becoming too much for her mother and neither was this identified as an issue by the carers. If any concerns had been expressed by Patricia Mullen, the carers or Mrs Mullen herself (who had full capacity), this would have been recorded and investigated.

Mrs Mullen also had daily contact with a neighbour with whom she had a close relationship. The neighbour spent most of each day with Mrs Mullen at her home and was present at the NHS home assessment prior to Mrs Mullen’s discharge from hospital. The neighbour did not express any concerns either to social care about any deterioration in her condition.

Office of the Chief Executive, City of Doncaster Council, Civic Office, Waterdale, Doncaster, DN1 3BU

The reference to the grab rail appears in the Ambulance records and is attributable to the paramedics who attended upon Mrs Mullen after her fall. This suggestion was not taken up by the occupational therapist and would not therefore have been followed up by social care.

Following the Inquest, we have made further enquiries and have established that the reference to the fall in the shower relates to an isolated event that was in fact documented by Newdon Care. I understand that this party was not required to give evidence at the Inquest and therefore this documentation was not available to the Inquest.

As a matter of practice, a single fall event would not be expected to raise a referral. Mrs Mullen was in receipt of care specifically to assist her with showering and any concerns in this respect would have been referred by the carers from Newdon Care to RDaSH for the falls service, occupational therapy, and physiotherapy, in the event that they considered this to be in Mrs Mullen’s best interests.

Learning from the incident: we strive as an organisation to improve our practices wherever we can and have reflected at length on the sad outcome for Mrs Mullen. In terms of action to be taken, we will continue to provide training to our staff and will continue to reinforce the need for accurate record keeping, particularly in relation to instances such as falls. We will also reinforce the need for carers and social care staff to escalate any concerns by making appropriate referrals to professionals who will be able to assess the risk and recommend further measures that might need to be put into place to address such risk. This will be further facilitated by the establishment of the “Home First Forum”.

Please let me know if I can be of any further assistance.