Dear Mr Arrow

NHS Devon Action Plan to address Regulation 28 in relation to the death of FKO Review of the protocols in Devon for dealing with individuals whose personal care and personal hygiene is inadequate due to their known personal circumstances particularly when this presents as a foreseeable risk of infection.

Regulation 28 Request from the Coroner A range of health and social care agencies provide care to people whose personal care and personal hygiene may be inadequate. This lack of personal care is described in the Care Act guidance as self-neglect and covers a wide range of behaviour such as neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. Details about what constitutes self-neglect, and the actions practitioners should take should be outlined in safeguarding adult policies.

Health and social care staff receive regular safeguarding training to improve their knowledge and competence. This training is delivered in a variety of ways including face to face sessions, e learning packages, webinars, newsletters, and briefings.

NHS Devon Integrated Care Board (ICB) is responsible for commissioning health services in Devon. It works in collaboration with NHS trusts, GPs, local authorities, and a range of agencies such as the voluntary and independent sector to form an integrated care system (ICS) known as One Devon.

NHS Devon ICB has reviewed its own safeguarding adult policies and has asked the safeguarding leads of those services that it commissions to review and update, if necessary, their safeguarding policies. A learning brief has been developed and disseminated to NHS commissioned healthcare providers to inform staff of this case and to support staff to understand that a lack of personal care and hygiene (including oral hygiene) can impact upon a person’s physical health and wellbeing and can lead to infection and sepsis; and to promote

Ian M. Arrow H.M. Coroner Derriford Business Park Plymouth PL6 5QZ Chief Nursing Officer NHS Devon County Hall Topsham Road Exeter EX2 4QD

18 October 2022

2 the recognition and support of those individuals who are unable to maintain their personal hygiene to manage the potential risk of infection and sepsis.

NHS Devon Commissioned Services NHS Devon ICB Safeguarding Adult Policy reviewed and amended NHS Commissioned Health Services Letter sent to request review and amendment of relevant policies and confirmation of review and outcome by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from providers. Independent Commissioned Health Services Letter sent to request review and amendment of relevant policies by 7th November 2022. NHS Devon Head of Safeguarding will ensure that assurance is received from providers.

General Practice NHS Devon ICB has delegated commissioning responsibility for General Practice services in Devon and provides safeguarding support to GP practices. Each practice is responsible for their safeguarding policies. Many use the Royal College of General Practitioners (RCGP) safeguarding adult policy template.

Safeguarding Adult Partnerships. As a partner of the two safeguarding adult partnerships in Devon; Torbay and Devon Safeguarding Adult Partnership (TDSAP) and Plymouth Safeguarding Adult Partnership (PSAP), NHS Devon will present the learning from this case and the need to ensure that multiagency safeguarding adult policies and adult social care policies are reviewed and updated, and changes disseminated to health and social care staff across the safeguarding partnerships. NHS Devon Head of Safeguarding will take a paper to the next Partnership meetings. Action Date of Partnership Meeting Paper to PSAP 13/10/22 Paper to TDSAP 13/12/22

I hope the above action plan adequately outlines the action taken or planned to be taken by NHS Devon to meet the Regulation 28 report to prevent future deaths issued’.