Dear Mr Landau

Re: Regulation 28 Report to Prevent Future Deaths (PFD) Report following the inquest into the death of Mr Samuel Pearson

Thank you for your correspondence received on 10 November 2022 containing a regulation 28 report to Prevent Future Deaths (PFD) following the conclusion of the inquest into the death of Mr Samuel Pearson on 6 July 2021. Firstly, I would like to offer sincere apologies to Mr Pearson’s family on behalf of both the ADAPT team and the Trust.

This response is made on behalf of Oxleas NHS Foundation Trust regarding the concern you set out in the PFD report. The concern specifically highlighted for the Trust is:

• A referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations.

At the inquest we confirmed that we had been reviewing our ADAPT Operational Policy, however, it had not concluded in terms of how we would inform referrers about service expectations. Our new policy is now complete, and it now clearly sets out the expectations of what information services users and the referrer will receive once the Team receive the referral in terms of waiting times. A copy of the new Operational Policy incorporating this new process is enclosed with this response.

The ADAPT Pathway provides focused, therapeutic interventions to adults residing within the three Boroughs who require care and treatment for Anxiety, Depression, Affective disorders, Personality disorders & Trauma.

An automated email will be generated and sent to the referrer:

Thank you for your referral. Please note that we aim to screen all referrals within 5 working days of receipt. The referral will also be discussed at the team's Multi-Disciplinary Team meeting so the appropriate plan can be drawn for the service user. The service user and you as Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford Kent DA2 7WG oxleas.nhs.uk 29 December 2022 FAO: HM Assistant Coroner Jonathan Landau South London Coroner’s Court

the referrer will receive a letter informing you of our current waiting times. If this referral is urgent and an urgent response is required, please contact the ADAPT duty worker (please insert the relevant team number here) who is the person who can support you with an escalation and or offer further advice.

In terms of contingency planning when services are not able to meet usual service expectations, all teams have in place a Business Continuity Plan which describes actions that they are required to take in circumstances such as situations where there may not be sufficient staff to safely deliver a service. At times when it is required to enact the plans communication with relevant stakeholders (including GPs and patients) will take place and is overseen by the Senior Management Team and through the Trust’s Governance structures. There is a yearly audit review undertaken with each team to ensure the plans are fit for purpose.

In conclusion, I am grateful for your report which has ensured that additional measures have been instituted so lessons are learned from the death of Mr Samuel Pearson. I hope I have addressed the concerns.

Your sincerely

Chief Executive

Enc: ADAPT Operational Policy

1

RESPONSE TO REGULATION 28 CORONER’S REPORT TO PREVENT FUTURE DEATHS

1. THIS RESPONSE IS MADE ON BEHALF OF London Borough of Bromley Council
2. REGULATION 28 REPORT This response follows a report by Assistant Coroner Jonathan Landau dated 10th November 2022 3 INVESTIGATION and INQUEST On 4 February 2022 an investigation was commenced into the death of Samuel Robert Pearson, aged 29. The investigation concluded at the end of the inquest on 12 October
2022. The narrative conclusion of the inquest was:

A van crashed into Samuel’s property on 20 June 2021. The accident caused a traumatic deterioration in his mental health. He was moved to accommodation that increased his anxiety, and no services were provided to mitigate that. On 6 July 2021, He took an overdose of Pregabalin and alcohol to help him sleep and he accidentally died as a result.

4 CIRCUMSTANCES OF THE DEATH Mr Pearson had complex mental and physical needs. He moved into his own accommodation in March 2021 following a period of good partnership working between relevant organisations. In June 2021, however, a van crashed into his home necessitating an emergency move to alternative accommodation. Mr Pearson struggled with the trauma of the accident, contributed to by the unsuitability of his temporary accommodation (a budget hotel).

5 CORONER’S CONCERNS The MATTERS OF CONCERN set out by the coroner are that – (1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants.

(2) In respect of Oxleas NHS Foundation Trust, a referral was made by Mr Pearson’s GP to the ADAPT service but at the time there was a 2-3 backlog in screening referrals and the GP was not made aware of the capacity issues. A robust contingency plan would ensure that referrers are informed when services are not able to meet usual service expectations. I heard evidence of openness to remedy these matters, which is welcome, but plans were at a very early stage by the date of the inquest.

2

6 ACTION TAKEN/TIMESCALE

1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.

2. In respect of London Borough of Bromley’s largest provider Clarion, Senior Management in the Housing Department (LA) made contact with a Clarion Manager on the 14/12/22 and 29/12/22, raising the need to review their Emergency Decant Policy around notification of emergency decants to LBB where there is a vulnerable household member. Clarion have been asked to set out a notification protocol within this policy so that this can be agreed with the Local Authority. It is appropriate for the Housing Association to do this as they know their processes best. The Local Authority have already provided contact details to Clarion for vulnerable adults and children’s services as well as an La housing contact, so that emergency decants can be notified as soon as the need is identified. On 03/01/23 Clarion informed us that they have considered their areas for improvement and these are now with their legal representatives for consideration and sign off before being sent to the Coroner.

3. Additionally, senior management in the LA Housing department have contacted Bromley Federation of Housing Associations to request that a meeting is convened to discuss this topic with their members, to ensure that they have due regard to arrangements for notifying LBB of emergency decants where there is a vulnerable household member.

7 THIS RESPONSE HAS BEEN PREPARED BY

The London Borough of Bromley’s Head of Allocations & Accommodation and Head of Service for Occupational Therapy

8 DATE OF RESPONSE 04/01/2023

Dear Sir,

Response to Regulation 28 report arising in the inquest of Samuel Pearson

I write in response on behalf of Clarion Housing Group to your Regulation 28 report dated 10 November 2022 which is addressed to the London Borough of Bromley Council (LBB), Oxleas NHS Foundation Trust and Clarion Housing Group (CHG).

I would firstly like to offer my condolences to Mr Pearson’s family on behalf of CHG.

Background As you know CHG are a provider of social housing and were pleased to be able to provide Samuel with accommodation in the form of an Assured Lifetime tenancy from the Spring of
2021. In the months following the move, CHG were liaising with the LBB’s occupational health team around the need for some further adaptations to the property.

Whilst at a relatively early stage there was recognition that Samuel would need to move out for a short period in order for this work to be undertaken. As I understand it from the inquest, Samuel’s mental health at this time was relatively stable and he had been discharged from the caseload of the mental health team, which was provided by Oxleas NHS Foundation Trust.

On 20 June 2021 matters were overtaken by a van that crashed into the front of Samuel’s property making it immediately uninhabitable. Information regarding this was received promptly from Samuel’s occupational therapist at LBB whose hope it was that some of the types of property that had been considered as part of the planned move could be available, noting he was residing with his mother at this point. It was quickly established with LBB that these properties (available through LBB) were not ready for occupation.

This notwithstanding CHG instigated an urgent assessment of need with Samuel and his mum and through a separate and specialist property search agency, located properties capable of meeting his needs, which was primarily for wheelchair access. At the time of the accident CHG assessed Samuel’s needs with his mum and were not given to think (having asked a direct question) that any other agency or professional needed to be immediately involved at that stage, noting that as part of the process CHG keep matters under close review.

As the inquest heard, the properties initially located were situated in South London approximately an hour away from his Bromley home and Samuel and his mum’s preference was to remain close to Bromley and familiar surroundings where possible. As such and following a further property search Clarion were able to locate wheelchair accessible hotel accommodation in Bromley which Samuel and his mum preferred. Clarion therefore took steps to arrange this, and Samuel moved in on 28 June 2021. Following the move our team took steps to check in with Samuel and his mum as to the suitability of the accommodation during the following week and were given no reason for concern.

This emergency provision ran alongside an urgent structural review of the damaged property in which it was coming to be understood how long remedial work would take, against which Clarion could keep under review with Samuel his family and others concerned the suitability of the temporary arrangement.

On 6 July 2021 CHG received an email from the LBB occupational therapist (who we understand had not at that point met with Samuel or his mother) querying the choice of accommodation, in response to which CHG took immediate steps to begin a process of review. Sadly, it was only a very short time later that Clarion came to be informed of Samuel’s death on that same day.

Review Since the inquest CHG have been reviewing its alternative accommodation and related assessment process to see what more if anything can reasonably be done to improve the system.

As part of the review and in line with our ongoing commitment to service improvement, CHG are considering how, if at all, good interagency working can be further embedded into the processes underpinning the provision of alternative accommodation in circumstances such as this.

This review remains ongoing at present and is expected to complete by the 31st January
2023.

I hope this is of assistance and assurance that the concerns raised are being considered and, where the need for improvement is identified, I can give you my assurance that it will be implemented.