Charlotte Duffield
PFD Report
All Responded
Ref: 2021-0334
All 1 response received
· Deadline: 3 Dec 2021
Coroner's Concerns (AI summary)
Adult Social Care failed to take appropriate safeguarding action despite significant police concerns, only attempting telephone contact and sending a letter, without making any physical visit to a vulnerable individual.
View full coroner's concerns
(1) On 3rd November 2020 Police officers attend Charlotte's home following a telephone call from her aunt expressing concern for her wellbeing. The Officers were concerned about the state of the property, Charlotte's clothing, her lack of emotional response and that she may not have access to money following the sudden loss of her father, Reviewing their report DS of Cumbria Constabulary made a referral to Adult Social Care on 5th November. Evidence seen at the inquest indicates that on receipt of the referral 3 attempts to telephone Charlotte were made on 6th, 9th & 10th November. As there was no reply a letter was sent asking her to contact them. There is a note that her case was discussed at a multidisciplinary meeting on 9th December 2021 but no further action seems to have been taken.
(2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person.
(2) Charlotte was referred due to significant concerns for her safety but no safeguarding action seems to have been taken. I am particularly concerned that after her failure to respond to attempted telephone contact no physical effort was made to visit her in person.
Responses
Action Taken
The Council has reviewed self-neglect policies, revised operational practice guidance, implemented a countywide operational Safeguarding Adults service, and is delivering training sessions; a practice learning session will be undertaken with the team directly involved in this case. (AI summary)
The Council has reviewed self-neglect policies, revised operational practice guidance, implemented a countywide operational Safeguarding Adults service, and is delivering training sessions; a practice learning session will be undertaken with the team directly involved in this case. (AI summary)
View full response
Dear Dr Shaw
Re: Regulation 28 Report to prevent future deaths
Further to your Regulation 28 report of the 5th October 2021, I write with confirmation of actions taken by Cumbria County Council (CCC). The safety of service users is of the utmost importance to CCC. We take your finding that there were matters giving rise to concern, and your opinion that there was a risk that future deaths may occur, extremely seriously. I wish to assure the Coroner that we proactively review our processes, and that the actions set out in this letter have been in place for many months. It is unfortunate that CCC were not provided the opportunity to present the work undertaken in advance of a Regulation 28 report being issued.
Within the Regulation 28 report concerns were raised that the operational response in this situation would leave others at risk if further action was not taken. The report implied that where concerns of self-neglect are identified, or following a referral, a direct face-to-face intervention would be required in order for the council to satisfy its duties.
To satisfy ourselves, and offer assurance to yourself, the Council confirms the following steps have been taken:
1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.
2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.
3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.
4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.
5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns. I trust the information and confirmation of action detailed in this letter give you assurance that suitable action has taken place to address your concerns.
Re: Regulation 28 Report to prevent future deaths
Further to your Regulation 28 report of the 5th October 2021, I write with confirmation of actions taken by Cumbria County Council (CCC). The safety of service users is of the utmost importance to CCC. We take your finding that there were matters giving rise to concern, and your opinion that there was a risk that future deaths may occur, extremely seriously. I wish to assure the Coroner that we proactively review our processes, and that the actions set out in this letter have been in place for many months. It is unfortunate that CCC were not provided the opportunity to present the work undertaken in advance of a Regulation 28 report being issued.
Within the Regulation 28 report concerns were raised that the operational response in this situation would leave others at risk if further action was not taken. The report implied that where concerns of self-neglect are identified, or following a referral, a direct face-to-face intervention would be required in order for the council to satisfy its duties.
To satisfy ourselves, and offer assurance to yourself, the Council confirms the following steps have been taken:
1. A systematic review of Cumbria Safeguarding Adults self-neglect policy and procedure documentation has been completed to clarify the roles, responsibilities, and duties across the safeguarding system.
2. The operational practice guidance in relation to self-neglect concerns has been reviewed and revised. The guidance reinforces the Council’s position that a face-to-face visit, in order to complete assessment and ensure the safety of the person at risk, must be undertaken to satisfy operational practice requirements and standards.
3. The Council has implemented a countywide operational Safeguarding Adults service, a dedicated safeguarding team providing support across the county, to ensure a consistent and compliant response for all safeguarding concerns, including concerns of self-neglect.
4. This dedicated Safeguarding Adults service is undertaking the delivery of training sessions across all partners to embed the review of self-neglect policy, procedure, and guidance.
5. Finally, a discrete practice learning session is being undertaken with the team directly involved in this case to ensure, from an operational point of view, that there is a clear and unequivocal position on how to respond to self-neglect concerns. I trust the information and confirmation of action detailed in this letter give you assurance that suitable action has taken place to address your concerns.
Sent To
- Cumbria County Council
Response Status
Linked responses
1 of 1
56-Day Deadline
3 Dec 2021
All responses received
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
An inquest was opened on 1st June 2021 and concluded at a final hearing on 5th October 2021. The short form conclusion reached was one of Self Neglect.
Circumstances of the Death
Charlotte Duffield was 40 years old, her body was discovered when police forced entry to her home on 4th February 2021 in response to concerns that Charlotte had not been seen for several weeks. It appeared she had been deceased for a significant period of time. Evidence heard at the inquest suggested that she lived a reclusive lifestyle and was not caring for herself, particularly after her father, with whom she lived, had died 3 months earlier. Due to advanced decomposition a pathologist was unable to determine the exact cause of death, however there were no suspicious circumstances to suggest death was other than natural
Copies Sent To
Chief Constable, Cumbria Constabulary, Dr , Duke St Surgery, Barrow
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.