Outlook Care response to: Sydney Piper; Prevention of future deaths report 10 May 2023 Background
• Date of report: 15/03/2024
• Ref: 2024-0145
• Deceased name: Sydney Piper
• Coroner name: Graeme Irvine
• Coroner Area: East London
• Category: Alcohol, drug and medication related deaths

Full report Sydney Piper: Prevention of future deaths report - Courts and Tribunals Judiciary

The MATTERS OF CONCERN are as follows.
1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day.

I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated. Response:
1. Following the initial safeguarding alert being raised and the issuing of notice for a Section 42 Enquiry, in partnership with key stakeholders on notification of death of Mr Piper, we implemented an action plan, appendix 1, which in summary consisted of:
• External feedback continuing to contribute to our reviews and improvement plans for services.
• Continued inclusion of feedback from stakeholders, London Borough of Waltham Forest (LBWF), in management reviews and how it meets the support and oversight of service delivery in local areas, ensuring feedback is evident in management decisions taken.
• Collaborative working with LBWF to ensure management decisions will benefit from the feedback and experience of LBWF/North-East London Foundation Trust (NELFT) partners.

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• Continued close working with LBWF to share opportunities and their wider experience/resources that can enhance the quality of the support provided by services.
• Raising awareness of LBWF Safeguarding Team and their role in ensuring customer safety from Abuse or Neglect. Local Safeguarding Information to be recirculated to raise awareness. All noticeboards reviewed and local Safeguarding information clearly displayed.
• Induction and Probation management reviewed to see what areas can be more effective.
• Supporting staff learning regarding their ‘Duty of Care’ including review of policy on Care and Support with a view to strengthen the focus on 1:1 support.
• Shared learning in teams to review how we evidence engagement and learning for customers using 1:1 support in the community and safeguarding best practice.
• Increase emphasis on Positive Behaviour Support principles evident in delivery and review of staff training and development to strengthen duty of care for customers using individual support.
• Share learning across the whole of the organisation at a learning event from this lived experience following conclusion of Organisational Safeguarding and MISPER Incident for the Management Team.
• Safeguarding Training for Managers with all Managers refreshing their Level 3 Safeguarding Training for Managers. Managers to supplement by attending their Local Authority Safeguarding for Managers training when it becomes available.
• Application of Missing Person’s Policy to strengthen how it is reflected individual’s risk assessments, support guidelines and Missing Person Information. Any recommendations to be made to Director of Care and Support with Chief Executive.
• Review potential risk for individual support and MISPER for all customers by identifying Risk Profiles for current customers and ensuring future customers are identified when they start to use our services. This will be subject to ongoing monitoring of customer’s changing needs.
• Staff awareness of Duty of Care when providing support to people at risk of MISPER is increased.
• GDPR Policy implementation is monitored at all stages of service closure to ensure there is secure storage available during decommissioning of service and transport of archiving to secure archive.
• Feedback from Customers on consultation during service closures will be more detailed.

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2. A full briefing was issued to our Board of Trustees who continue to provide scrutiny and oversight of our progress. The action plan implementation is led by the Chief Executive and real time reporting to the Board of Trustees continues alongside regular briefings issued to all of the workforce.
3. We participated in the Safeguarding Adults Board review led by the London Borough of Waltham Forest, appendix 2. We revised our action plan accordingly based on learning from this process.
4. In response to the Regulation 28 Notice issued by the Coroner and the matters of concern noted, the following actions have also been implemented:
• Staff briefings held with all staff led by Chief Executive, Director of Care and Support and Managers.
• Discussions with all staff during staff meetings.
• Further review and relaunch of Missing Persons Policy, appendix 3.
• Workforce review of understanding of the Missing Persons Policy, see appendix 4. To date we have a >90% response rate evidencing good understanding.
• Further review of updated risk assessments for all service users supported in relation to Herbert Protocol, missing persons process and delivery of 1:1 support in the community.
• Training for all staff in mitigation service user risk of going missing and managing the process should a service user go missing, emphasising: o the role of day-to-day risk assessment as a preventative measure for service users at risk of going missing. o the critical nature of the golden hour should a missing person incident occur.
• The use of a day to day, app based, risk assessment completed every time a service user is supported in the community, appendix 5. This process was implemented on 22 March 2024 and to date 1098 risk assessments have been completed and records stored securely, reviewed monthly by the Director of Care and Support to identify trends or areas of concern. To date the risk assessments have been completed by 458 staff.
• Spot checks on 1:1 support being delivered to service users in the community to check for both safety and quality as well as validating that our action plan is being implemented in practice, appendix 6. To date 21 spot checks have been completed and reported on to the Executive Management Team. Where performance of staff has fallen below our standards, staff are undergoing further training/performance management and cease to deliver community- based support until they reach the required competency level.

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• Guidance on the delivery of 1:1 support and the importance of maintaining a ‘line of sight’ has been issued, in form of video briefing, written guidance, posters, key facts cards issued to staff name badges, see appendix 7.
5. Further actions scheduled for completion by end of June 2024 include:
• Completion of an unannounced Business Continuity Management test in relation to a Missing Person incident, to be repeated annually.
• Including audits of risk management process in relation to Missing Person and delivery of community support to mitigate risk of service users going missing into our annual audit schedule, to be completed twice per year on an ongoing basis. Outcomes will be reported to Board of Trustees for scrutiny and oversight.
• Revised induction and handover formats that include specific reference to Missing Person risk and mitigation of such risk, see appendix 8. Finally, in October 2024, we will be hosting a learning event for all stakeholders, partners and other providers, to share our learning and revised procedures, stemming from this tragic incident.

Please do not hesitate to contact me if you have any questions.

Dear H.M. Senior Coroner Graeme Irvine,

CQC response to prevention of future deaths report in respect of Mr Sydney Piper

Thank you for naming the Care Quality Commission (CQC) as a respondent to the above report. I apologise again for the delay responding, caused by reorganisation within CQC, and I’m grateful to you for allowing an extension to the deadline for response.

At CQC, we make sure that health and care services in England provide people with safe, effective and high-quality care.

I note from section 5 of the report that your concerns are as follows:

1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day.

Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone:

Fax:

I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated.

2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.

Regarding the first concern, Mr Piper was resident at Waterside Lodge Recovery Centre, a care home run by Outlook Care. Outlook Care are registered with CQC to provide the regulated activity of ‘Accommodation for persons who require nursing or personal care’. We last inspected Waterside Lodge Recovery Centre in December 2019, rating it as Good under our five domains of Safe, Effective, Caring, Responsive and Well-led. Outlook Care closed Waterside Lodge Recovery Centre on 31 March
2023.

We have reviewed whether there has been a failure by Outlook Care or the Registered Manager for Waterside Lodge (Registered Persons), to provide Mr Piper with safe care and treatment causing Mr Piper avoidable harm. CQC does not have the power to take enforcement action against individuals who are not Registered Persons, except in circumstances where individual directors or members may be held individually liable for the commission of the offence by a registered provider that is a body corporate or unincorporated association, under sections 91 or 92 of the Health and Social Care Act
2008. Those circumstances do not arise in this case. On reviewing the available evidence, we do not find that there are grounds to proceed with a criminal investigation against a Registered Person.

We have reviewed the information we hold regarding Waterside Lodge Recovery Centre and asked Outlook Care to provide us with a copy of their response to H.M Senior Coroner. We note that although Outlook Care are not able to take action at Waterside Lodge due to its closure, they have committed to changes across their remaining nine locations to prevent such a sad event as this happening again. The changes include review of missing person policy, training for staff, additional risk assessments for supporting people using the service in the community and spot checks on one to one community visit support. We further note that the majority of these changes are due to be completed by the end of June 2024. Working with the CQC team covering the area where Outlook Care’s head office is located, we will request and review evidence of completion of these actions to ensure this has taken place. As part of CQC’s ongoing monitoring of registered providers, we will seek further evidence from Outlook Care to assure ourselves that all the changes made have been embedded into their ways of working.

With reference to the report’s second area of concern, while CQC shares this concern, I note that the Metropolitan Police Service are also a named respondent and trust that they will be best placed to address this.

I hope the above assures H.M. Senior Coroner that CQC are monitoring Outlook Care to ensure that appropriate action has been taken to prevent future deaths.

This is the London Borough of Waltham Forest’s (the “Local Authority”) response to the Regulation 28 Report Reference 22449640 in respect of Sydney Piper.

The Concerns raised were:
1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day. I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated.
2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm.

The Local Authority did not employ the support worker or commission the service that employed them in this case. We set out below the processes by which such services are monitored when commissioned by the Local Authority.

The Local Authority does not own or manage the relevant part of Epping Forest or the surrounding land in this case. It is understood that the relevant land is owned and managed by the Corporation of London. However, we set out below how parks and open spaces within Local Authority remit are managed, as well as the safeguards in place for land owned and managed by third parties.

1. SPECIALIST RESIDENTIAL/SUPPORTED LIVING
1.1. In this case the Supported Living for Mr Piper was commissioned by the NHS Trust. The Local Authority had no involvement in commissioning that service in this case and Mr Piper was not cared for by the Local Authority under the Care Act 2014.

1.2. Where an individual’s care needs are assessed as needing to be met by provision of residential care by a Local Authority, then the Local Authority would have duties to that individual under the Care Act 2014. The nature and extent of those duties would depend on the particular circumstances, but would be governed by the applicable law, statutory guidance and Local Authority policy.
1.3. Where a placement was to be commissioned by the Local Authority, its Brokerage team would source a placement that could effectively meet the individual’s needs. That team has a number of safeguards in place to ensure that placements are suitable and appropriate:

a) Where a provider is registered with the Care Quality Commission, the Local Authority will only be brokered if the latest rating with the CQC is “Good” or “Outstanding” b) There will be consultation with the Quality Assurance team, who monitor providers within the Borough, for their feedback. c) For providers outside of the Borough, contact will be made with the host local authority for their feedback. d) Once a provider is deemed provisionally suitable, the Quality Assurance team undertake a further review that assesses the financial standing, a review of the provider’s key policies and procedures including but not limited to, Safeguarding, Support Planning, and Incident reporting, Health and Safety, insurance, and the provider’s Quality Assurance framework.

1.4. In terms of ongoing monitoring, the Quality Assurance monitoring team undertake at least one visit annually to all provisions in the Borough. Where concerns are identified and a service improvement plan has been implemented, the team will visit with greater frequency to support the improvement process. The provisions are monitored on a number of key areas: Staffing, Support/Care, Health and Safety, Policy and Procedure, Governance, Quality Assurance, Resident feedback, staff feedback, Medication Safeguarding and MCA/DoLs. A report is sent to the provider detailing actions required within a given timeframe.
1.5. An individual in such a placement would also have the benefit of a review of their Care and Support plan on at least an annual basis that would include considering the appropriateness of the particular placement.

2. SAFEGUARDING
2.1. Duties
2.1.1. The Local Authority has a duty to make a Safeguarding Enquiry under section 42 of the Care Act 2014 where it:

has reasonable cause to suspect that an adult in its area (whether or not ordinarily resident there)— (a) has needs for care and support (whether or not the authority is meeting any of those needs), (b) is experiencing, or is at risk of, abuse or neglect, and (c) as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it.

2.2. Making a referral
2.2.1. The majority of Safeguarding concerns are raised via the Multi Agency Safeguarding Hub (“MASH”) or the Adult Front Door service and generally come from direct concerns of professionals from various disciplines.
2.2.2. Contact details for MASH are widely available and, for example, come up as the first result in a Google search for “safeguarding Waltham Forest”.

2.2.3. The first result in that search is a page from the Local Authority’s website about MASH, explaining what it is and providing an email address, telephone numbers for the working day and out of hours and a MASH referral form for professionals’ use.

That page also indicates that urgent concerns should be raised by contacting the safeguarding team directly by telephone, and provides the telephone number.

2.2.4. The second result is another Local Authority webpage headed, “How to report adult safeguarding concerns”. It contains the telephone number for the Safeguarding Adults Team and a link to a Safeguarding Alert form that can be completed online.

2.3. Process
2.3.1. Where a concern relates to an individual that is open to a Local Authority team, the concern will be recorded and progressed to that team for them to establish whether the section 42 criteria are met. That is on the basis that they are likely to have some direct knowledge of the person concerned.
2.3.2. Where the individual is not known to the Local Authority, or not open to a team (and in this case, Mr Piper was not known to the Local Authority other than as a DOLS supervisory body), the adult MASH team will be responsible for establishing if the section 42 criteria are met.
2.3.3. In either case, if the criteria are met, the individual will be allocated to the most relevant team that most closely matches their presenting care and support team. For example, if the primary support needs relate to mental health, then this would be the Community Recovery Team in Northeast London NHS Foundation Trust (“NEFLT”), which is part of a prescribed arrangement between the Local Authority and NHS under section 75 of the National Health Service Act 2006.

2.4. Policy
2.4.1. The Local Authority is bound by the London Multi-Agency Safeguarding Policy & Procedures as agreed by the London Safeguarding Adults Board.
2.4.2. The policy provides Indicative Timescales:

INDICATIVE TIMESCALES Stage one: Concerns Immediate action in cases of emergency Within one working day in other cases

Stage two: Enquiries
• Initial conversation

• Planning meetings

Same day concern received if not already taken place

Within 5 working days

• Enquiry actions

• Agreeing outcomes

Target time within 20 working days

Within 5 working days of enquiry report

2.4.3. All enquiries are triaged the same day.

2.5. In this case
2.5.1. It is very likely that a vulnerable person such as Mr Piper going missing would meet the section 42 criteria. In this case, the Local Authority did not receive the referral because it was sent to a wrong email address.
2.5.2. All emails correctly sent to the Adult Front Door and MASH receive an immediate automated response to acknowledge receipt.
2.5.3. Had the referral been received, it is likely that the first step would have been to make contact with the police to share information.
2.5.4. The enquiry would also have been allocated to NELFT because of the mental health needs here.

3. ROUGH SLEEPING
3.1. All parks and open spaces within the Local Authority’s remit are monitored as follows:

a) Through a weekly regime of litter picking by an appointed contractor. The contractor will report any rough-sleepers, tents or evidence of rough-sleeping that is identified to the Local Authority rough-sleeper team. b) Through Park Officers and officers in the Sports and Leisure team carrying out regular inspections and making referrals.

3.2. The Council’s Rough Sleeper team makes three attempts to engage with individuals identified during the inspections. They offer support and assistance to connect them with appropriate services. They also make a referral to

StreetLink, a platform that connects people sleeping rough to other agencies and charities, including St Mungo’s.
3.3. Where appropriate, Neighbourhood Officers can issue Community Protection Notices instructing individuals to move on. If necessary, they collaborate with local police to enforce these notices.
3.4. The Local Authority has a contract in place to cut back overgrown vegetation, particularly that which may attract rough sleepers.
3.5. Where land is owned by other parties, Neighbourhood Officers liaise with those landowners to ensure that appropriate action is taken.

London Borough Waltham Forest

Dear Mr Irvine I am the Deputy Assistant Commissioner for Frontline Policing in the Metropolitan Police Service (MPS" ). On behalf of the Commissioner of Police of the Metropolis, write t0 provide the response to the matter of concern addressed to the MPS in your Report to Prevent Future Deaths dated 1St March 2024 On behalfof the MPS, may [ first of all express my sincere condolences to the family and friends of Mr Sydney our thoughts and sympathies are much with them. TheCoroner "Matter of Concemn' The Prevention of Future Deaths' report dated 15t March 2024 records: - "2 Mr Piper'$ death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm MPS Response The MPS have liaised with the Coroner and have been unable to identify any other deaths in this area which would suggest any specific or ongoing risk to public safety, or significant criminal activity. In accordance with statutory guidance; any unauthorised encampment which poses a risk of safety to occupants and others will be addressed as a public safety/public health issue through a multi-agency approach led by the local authority: Further, where individual crimes are reported there will be & duty for police to investigate_ Piper, very along drug

METROPOLITAN POLICE I can confirm that ongoing work is being undertaken the respective local authorities and there is strategic policelpartnership joint working to focus on rough sleeping: The police neighbourhood teams are supporting the local authority strategy for rough sleeping, which includes community safety, housing and enforcement_ We have increased engagement with local residents who use the forest and surrounding environs to encourage reporting of rough sleeping become aware of directly to the Local Authority. The MPS is working closely with the Local Authorities and the Epping Forest Park Rangers to ensure any early identification of rough sleeping is addressed as a partnership.