Emma Turner
PFD Report
Partially Responded
Ref: 2026-0115
Coroner's Concerns (AI summary)
Poor information sharing and lack of system connectivity between agencies hindered care for a vulnerable adult. The GP safeguarding referral form was inadequate, causing delays in response.
View full coroner's concerns
CONTROLLED It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests. The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery. Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way.
Responses
Action Taken
• A single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. • Guidance to support people with understanding safeguarding and making referrals, is available on both Derby Safeguarding Adult Board and Derbyshire Safeguarding Adult Board websites, and links to this guidance will be further embedded within the digital referral forms. • It is clear within the joint policy and procedures that referrals should be made by telephone in the first instance, as this enables a timely and robust response to the concerns being raised. (AI summary)
• A single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. • Guidance to support people with understanding safeguarding and making referrals, is available on both Derby Safeguarding Adult Board and Derbyshire Safeguarding Adult Board websites, and links to this guidance will be further embedded within the digital referral forms. • It is clear within the joint policy and procedures that referrals should be made by telephone in the first instance, as this enables a timely and robust response to the concerns being raised. (AI summary)
View full response
Dear Madam Re: Response Regulation 28: REPORT TO PREVENT FUTURE DEATHS
This is Derby City Council and Derbyshire County Council's response to your report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25 February 2026, following the death of Emma Irene Turner on 29 January 2023.
On behalf of Derby City Council and Derbyshire County Council, we wish to express our sincere condolences to Miss Turner’s family and to acknowledge the issues highlighted in your Regulation 28 report.
Across Derby and Derbyshire there is a joined-up, partnership approach to safeguarding adults, underpinned by a joint Safeguarding Adults Policy which operates across both the Derby Safeguarding Adults Board and the Derbyshire Safeguarding Adults Board areas. As part of this partnership approach, a single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. This form is available online for members of the public, all partner agencies and providers, including GP practices, to use when making safeguarding referrals.
Guidance to support people with understanding safeguarding and making referrals, is available on both Derby Safeguarding Adult Board and Derbyshire Safeguarding Adult Board websites, and links to this guidance will be further embedded within the digital referral forms. It is also clear within the joint policy and procedures that referrals should be
HM ASSISTANT CORONER SABYTA KAUSHAL
Date: 23.04.2026
made by telephone in the first instance, as this enables a timely and robust response to the concerns being raised.
The Safeguarding Adults Referral Form is a single document, used to refer all types of abuse and neglect for any adult with care and support needs who may be at risk of, or experiencing, abuse or neglect, and who is unable to protect themselves because of those care and support needs. Because it is used by a wide range of referrers (for example, health professionals, care providers, police, community mental health teams, voluntary and community sector organisations, and members of the public), the form must be sufficiently flexible to: cover all types of abuse and neglect be applicable to all adults with care and support needs enable professionals and the public to provide the key information required by the local authority to commence safeguarding adults enquiries in a timely and proportionate way.
We recognise the concerns raised that some sections of the current template are less directly relevant to GPs and that this may increase the risk of key clinical or contextual information not being clearly set out and potentially delay the safeguarding team’s response. In recognition of this, Derby City Council and Derbyshire County Council have worked in partnership to collate feedback from partner agencies, including GPs, specifically on the structure, content and usability of the Safeguarding Adults Referral Form.
Using this feedback, we are co-producing a revised Safeguarding Adults Referral Form with partners. The aim is to make the form more streamlined and effective for all referrers, while maintaining the flexibility needed for use across different agencies and settings. The revisions will seek to: clarify and prioritise the information most critical for timely safeguarding decision-making ensure that questions are proportionate and as relevant as possible to the wide range of referrers, including GPs reduce unnecessary duplication and complexity for practitioners.
This work is underway and is being taken forward as a joint piece of work across Derby and Derbyshire. The revised Safeguarding Adults Referral Form, reflecting this co-produced approach, will be completed and implemented by the end of July 2026.
This is Derby City Council and Derbyshire County Council's response to your report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 25 February 2026, following the death of Emma Irene Turner on 29 January 2023.
On behalf of Derby City Council and Derbyshire County Council, we wish to express our sincere condolences to Miss Turner’s family and to acknowledge the issues highlighted in your Regulation 28 report.
Across Derby and Derbyshire there is a joined-up, partnership approach to safeguarding adults, underpinned by a joint Safeguarding Adults Policy which operates across both the Derby Safeguarding Adults Board and the Derbyshire Safeguarding Adults Board areas. As part of this partnership approach, a single Safeguarding Adults Referral Form has been developed and implemented for use across Derby City and Derbyshire County. This form is available online for members of the public, all partner agencies and providers, including GP practices, to use when making safeguarding referrals.
Guidance to support people with understanding safeguarding and making referrals, is available on both Derby Safeguarding Adult Board and Derbyshire Safeguarding Adult Board websites, and links to this guidance will be further embedded within the digital referral forms. It is also clear within the joint policy and procedures that referrals should be
HM ASSISTANT CORONER SABYTA KAUSHAL
Date: 23.04.2026
made by telephone in the first instance, as this enables a timely and robust response to the concerns being raised.
The Safeguarding Adults Referral Form is a single document, used to refer all types of abuse and neglect for any adult with care and support needs who may be at risk of, or experiencing, abuse or neglect, and who is unable to protect themselves because of those care and support needs. Because it is used by a wide range of referrers (for example, health professionals, care providers, police, community mental health teams, voluntary and community sector organisations, and members of the public), the form must be sufficiently flexible to: cover all types of abuse and neglect be applicable to all adults with care and support needs enable professionals and the public to provide the key information required by the local authority to commence safeguarding adults enquiries in a timely and proportionate way.
We recognise the concerns raised that some sections of the current template are less directly relevant to GPs and that this may increase the risk of key clinical or contextual information not being clearly set out and potentially delay the safeguarding team’s response. In recognition of this, Derby City Council and Derbyshire County Council have worked in partnership to collate feedback from partner agencies, including GPs, specifically on the structure, content and usability of the Safeguarding Adults Referral Form.
Using this feedback, we are co-producing a revised Safeguarding Adults Referral Form with partners. The aim is to make the form more streamlined and effective for all referrers, while maintaining the flexibility needed for use across different agencies and settings. The revisions will seek to: clarify and prioritise the information most critical for timely safeguarding decision-making ensure that questions are proportionate and as relevant as possible to the wide range of referrers, including GPs reduce unnecessary duplication and complexity for practitioners.
This work is underway and is being taken forward as a joint piece of work across Derby and Derbyshire. The revised Safeguarding Adults Referral Form, reflecting this co-produced approach, will be completed and implemented by the end of July 2026.
Sent To
- Derby City Council
- Derbyshire County Council
Response Status
Linked responses
1 of 2
56-Day Deadline
22 Apr 2026
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 07 February 2023 I commenced an investigation into the death of Emma Irene TURNER aged 30. The investigation concluded at the end of the inquest on 06 January 2026. The conclusion of the inquest was that: Emma Irene Turner died on 29th January 2023 at her home address of 2 Betjeman Square Derby. She was profoundly disabled with quadriplegic athetoid cerebral palsy since birth. She lacked capacity. Single and multi-agency processes for discussing Emma's clinical and social care needs were not utilised regularly and in a timely way for her benefit nor were safeguarding adult referrals fully addressed. Speech and language therapists did not see Emma in person for the 11 years between her transition from child to adult services. When she had been assessed by the speech and language therapists, they advised she should only eat pureed food. There was no face to face assessment regarding her clinical needs, her social needs nor adequate welfare checks from 2019 until her death. On 29th January 2023, having eaten some cake, her airway became obstructed as a result of vomit and that sadly resulted in her death.
Circumstances of the Death
Emma Irene Turner died on 29th January 2023 at her home address of 2 Betjeman Square Derby. She was profoundly disabled with quadriplegic athetoid cerebral palsy since birth. She lacked capacity. Single and multi-agency processes for discussing Emma's clinical and social care needs were not utilised regularly and in a timely way for her benefit nor were safeguarding adult referrals fully addressed. Speech and language therapists did not see Emma in person for the 11 years between her transition from child to adult services. When she had been assessed by the speech and language therapists, they advised she should only eat pureed food. There was no face to face assessment regarding her clinical needs, her social needs nor adequate welfare checks from 2019 until her death. On 29th January 2023, having eaten some cake, her airway became obstructed as a result of vomit and that sadly resulted in her death.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.