Dear Sir

Glenn MacMartin (deceased) Inquest date: 15 and 24 March 2021

I write on behalf of the Devon Partnership NHS Trust (“the Trust”) further to the Inquest touching the death of the above named and the Regulation 28 Report to Prevent Future Deaths (“the Report”) issued by you on 7 May 2021.

I note that the Report is addressed to the Trust, the Care Quality Commission (“the CQC”) and Plymouth Safeguarding Adult Partnership.

I note that in section 5 you have raised the following matter of concern:

“The deceased was accommodated in a Care Home that was subsequently formally closed due to poor service.

The selection of the accommodation was made without a physical inspection of its suitability for the deceased by the organisation with responsibility for providing the accommodation before the deceased took up residence.”

Further I note that in section 6 of the Report that you set out action should be taken as follows:

“In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.

Please review the selection and monitoring of care home provision and care given by private care home providers who are funded by Devon Partnership Trust.

Please review what action to take when care homes are closed to ensure lessons are learned from such closures.

Please indicate when a report on such a review may be forthcoming.”

We had not understood on the conclusion of the inquest that you were intending to issue the Report, and it would be helpful to understand the subsequent information or concerns you have received that has resulted in this. Notwithstanding this, the Trust sets out its response below.

Response of Devon Partnership NHS Trust

I understand at the Inquest you admitted into evidence the witness statement of dated 5 March 2021 and also heard oral evidence from on 15 March 2021.

is the Head of Profession for Social Work and Directorate Manager for Social Care. As such, she is in a position to address the extensive questions in relation to the commissioning of Mr MacMartin’s placement raised by the family and yourself at Inquest.

Selection of accommodation without physical inspection

In line with the evidence set given by at the Inquest, in the time since Mr MacMartin’s death, a decision has been made that mental health social care will not contract with new providers without visiting the facilities to gain assurance of suitability.

I hope that this reassures you that where the Trust is responsible for commissioning care at a new placement, that a physical inspection of that placement is undertaken to ensure that it is a suitable and appropriate environment according to the person’s assessed care needs.

Selection and monitoring of placements

You will, I am sure, appreciate that it is not only the Trust which commissions individuals’ care with private care home providers. Furthermore, in respect of the ongoing monitoring and regulation of those providers, I can only provide reassurance on behalf of this Trust.

The Trust does reasonably rely on the inspections and ratings provided by the CQC in terms of quality assurance and adherence to any relevant regulations. I understand that at the time of Mr MacMartin’s placement at Annette’s Care Home (“the Care Home”) in Plymouth the corresponding CQC report was reviewed. It was confirmed that the Care Home was rated by the CQC as “Good”. Furthermore, at the time Devon County Council had an existing contract in place with the Care Home. The contract for services entered into included the following provisions around quality assurance:

 The provider shall provide the service in accordance with its obligations under the contract and with the skill, care and diligence to be expected of a competent provider of a residential care home service.  The provider must comply with all requirements of the Care Standards Act 2000 and the National Minimum Standards.  To provide and supervise the proper provision of the service and to meet the assessed needs of the service users, including outpatient appointments, emergency hospital admissions and to partake in other activities outside of the home.

The Trust was further reassured by the fact that Mr MacMartin had periods of formal leave under section 17 Mental Health Act 1983 (“the MHA”) to the Care Home from 17 to 20 May 2018; 24 to 30 May 2018; 8 June 2018; 13 to 15 June 2018; and 13 to 28 August 2018. All of these periods of leave went ahead without incident, allowing Mr MacMartin to become familiar with the Care Home and its staff and enabled the Care Home to become familiar with Mr MacMartin’s individual needs.

At the time therefore the Trust’s Mental Health Social Care Panel were reassured that the Care Home was an appropriate service with which to contract and place Mr MacMartin.

Such processes will continue to take place in order to ensure that patients who are being discharged from liability to be detained under the MHA receive suitable and appropriate care in the placement to which they are being discharged.

The Trust’s discharge policy also includes a seven day follow up directly with the patient. Although not a formal review, it is an opportunity to “touch base” with the person and act upon any identified needs. No concerns were raised in Mr MacMartin’s case.

Again, this seven day follow up is a process which continues to take place in line with good practice.

As a person who had been detained under section 3 MHA, Mr MacMartin was in receipt of section 117 MHA aftercare. As identified in the evidence provided by Ms Adams, the Trust’s policy for section 117 MHA aftercare requires a review of the care and care plan at six months. I understand that in Mr MacMartin’s case, this review in fact took place after three months.

Again, this is a process which continues to date, not only giving assurance that the person is adequately cared for but also to ensure there is appropriate clinical input for the individual and to address any concerns or change in the person’s needs.

Learning lessons

Where concerns about an individual’s care are raised with the Trust, whether by the care provider, family members, professionals or the individual themselves, the Trust is under a duty to consider whether a safeguarding referral needs to be made to the relevant Local Authority. It is then for the relevant Local Authority under section 42 Care Act 2014 to identify whether further investigations ought to be undertaken and if so by whom. This provides further safety netting in respect of any concerns which could be raised by or on behalf of the individual.

As above, it is otherwise for the CQC to monitor, review and if necessary enforce any of the relevant regulatory provisions of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Insofar as any incidents relating to any individuals for whom the Trust responsible, the Trust will consider whether the relevant thresholds are reached for it to undertake its own review by way of a Root Cause Analysis investigation. This entails a detailed review of the incident(s), identification of the root cause(s) and recommendations and actions to be taken. It also identifies who is responsible for undertaking those actions and by when. This enables the Trust to learn from incidents (which could include, but not limited to, the closure of a care home) and ensure actions are implemented.

Improvements in service delivery

Again, I can otherwise reassure you that additional improvement measures have, or will be taken as follows:

 A redesign of social care delivery within the Trust is now complete, with dedicated social workers in each community mental health team, who are responsible for both the sourcing and review of social care placements and support;  There is a comprehensive, Care Act compliant assessment completed with the person. This documents the person’s needs, strengths, wishes and family and social networks. This is used in conjunction with health assessments to inform both care and support plans and commissioning;

 Social workers form a system with the social care contract and review team and associated processes. The senior commissioning officers and the locality social work managers work closely together and have scheduled monthly meetings;  The community social work managers have linked with the forensic social work team at Langdon Hospital (a secure service for which the Trust is responsible, and where Mr MacMartin had been detained) to strengthen links and ensure that processes and practice relating to the sourcing and review of social care is uniform across all services and that the contract and review team are fully cited on all proposed placements prior to any contracting taking place;  Funding has been secured for a Local Authority assigned social worker to join the community forensic team from 1 April 2021. This social worker will provide a vital link between the social care teams and forensic services at the point of transition;  A protocol to specifically address the placing of people outside of the Trust’s geographical area has been developed. This will strengthen our existing practice by providing a clear guide for our teams and follows the guidance within the advice note for directors and of adult social services commissioning out of area care and support services produced by ADASS. It also highlights the need to ensure the provider has arrangements in place and contains provisions to assure of suitability of service and face to face reviews. The Trust has also developed an Out of County Care Provider Monitoring form as part of its provider assurance service. I attach the protocol and Monitoring form for your information.

We trust that the above provides you with the reassurances that you seek but if you have any queries please do not hesitate to contact me.

Dear HM Coroner Arrow We write to provide the formal response of the Care Quality Commission (CQC) to the Regulation 28 Preventing Future Deaths report made by HM Coroner Ian Arrow following the inquest into the death of Glenn MacMartin (‘the Regulation 28 Report’). In the Regulation 28 report HM Coroner raised the following concerns:
1. The deceased was accommodated in a care home that was subsequently formally closed due to poor service
2. Review the selection and monitoring of care home provision and care given by private care home providers who are funded by Devon Partnership
3. Review what actions are taken when care homes are closed to ensure lessons are learnt from such closures.

In our formal response to the Regulation 28 report the CQC deals with each concern in turn and sets out what action it has taken to date to address the concerns and/or what actions we are proposing to take to address them.

1. The deceased was accommodated in a care home that was subsequently formally closed due to poor service Mr MacMartin was accommodated at Annette’s Care on 7 September 2018. On that date the service was rated good. Following a comprehensive inspection on 20 March 2019 the CQC rated Annette’s Care as Inadequate overall and subsequently took enforcement action that resulted in the cancellation of Annette’s Care Limited, and the closure of the care home, Annette’s Care. CQC working closed with the local

authority during this period. The circumstances of Mr MacMartin’s death are of great regret to the CQC and we offer our condolences to Mr MacMartin’s family. The CQC received low level information of concern in relation to the service location Annette’s Care. Between October 2018 and December 2018 there were two concerns raised. On each occasion CQC reviewed the information and assessed the risk to service users to inform what action CQC should take. In line with CQC methodology at the time we decided not to take regulatory action following reassurances that we received from Annette’s Care, Plymouth County Council and the Local Authority Adult Safeguarding Team. In line with our methodology in relation to low level concerns, we noted those areas of concern to inform a future inspection. CQC undertook a comprehensive inspection of the service in March 2019 following receipt of further concerns. These concerns came from the inspection in February 2019 of a different location owned by the same Registered Provider. That inspection resulted in the CQC taking civil enforcement action against the Registered Provider. In light of this information a decision was made to inspect Annette’s Care in March 2019. The comprehensive inspection looked at all five key questions (safe, effective, caring, responsive and well led). The inspection methodology included speaking with and pathway tracking the care of Mr Glenn McMartin. The CQC found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated Inadequate overall. A copy of the report can be found on our website at

The Local Authorities have a statutory duty to investigate allegations of abuse in line with their legal responsibilities pertaining to the Care Act 2014. Therefore, following the inspection, the CQC immediately spoke with Plymouth City Council to share a summary of their inspection findings as well as to raise safeguarding alerts, of both an individual and whole service nature. One of those individual safeguarding alerts related specifically to Mr. Glenn MacMartin. As part of CQC methodology, CQC also undertook an initial assessment of the specific incident concerning Mr McMartin to determine whether there were reasonable grounds to suspect that a criminal offence may have been committed by the provider Annette’s Care Limited under Regulations 12(1) and 22(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We determined there was insufficient evidence of provider level failure to provide safe care and treatment under Regulation 12(1) resulting in avoidable harm to Mr McMartin or exposing him to a significant risk of such harm occurring. The CQC has undertaken an internal review of the actions it took in relation to Annette’s Care Limited and the case of Mr MacMartin. We are satisfied that the decision taken to inspect Annette’s Care was timely, proportionate and justified, and complied with CQC methodology. We are also satisfied that the determination not to proceed to a formal criminal investigation following the initial assessment was also proportionate, justified and in line with CQC methodology. These assessments will be reconsidered in light of any recommendations made or findings from the joint agency Learning Event, which we refer to later in this response.

Review the selection and monitoring of care home provision and care given by private care home providers who are funded by Devon Partnership. The CQC was established on 1 April 2009 by the Health and Social Care Act 2008 (‘the Act’). The CQC is the independent regulator of Healthcare, Adult Social Care, Hospital and Community Trusts and Primary Care Services in England. The CQC also protects the interests of vulnerable people, including those whose rights are restricted under the Mental Health Act. The Act introduced a single registration system which applies to both Healthcare and Adult Social Care Services. We recognise that the Local Authority also has a role in selection and monitoring of a service, as well as in relation to safeguarding. We anticipate the Local Authority will summarise this role in their response to the Regulation 28 report. We also recognise the importance of ensuring the cooperation and collaboration where appropriate between CQC and the Local Authority. In practice, as in this case, CQC proactively attend regular meetings with the Local Authority to share information about registered services. This forms part of the intelligence we use to inform CQC decisions on whether and what regulatory actions CQC might consider. CQC also attend safeguarding meetings where safeguarding issues have been identified and contribute to the safeguarding plan where appropriate. Once registered with the CQC, Registered Providers such as Annette’s Care Limited are required to comply with conditions placed on their registration and to comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 (‘Regulated Activities Regulations 2010’) and the CQC (Registration) Regulations 2009 (‘the Regulations’). The Regulations set out the fundamental standards of quality and safety that service users have a right to expect. The Regulated Activities Regulations 2010 were replaced by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (RAR 2014) (‘the Regulated Activities Regulations 2014’) which came into effect from 1 April 2015. The Regulated Activities Regulations 2014, sometimes called the Fundamental Standards Regulations, include a requirement on the registered provider to undertake risk assessments, prior to and upon arrival of a service user, and on a continuing basis thereafter, to ensure that the provider is capable of and is meeting, the needs of service users, including providing safe care and treatment under Regulation 12(1) RAR 2014. The Regulated Activities Regulations 2014 apply to all Registered Providers in setting out the duties they must meet and does not distinguish between private or Local Authority care services. The CQC are responsible for monitoring, inspecting and regulating services to make sure they meet the fundamental standards of quality and safety including, where appropriate, taking civil and/or criminal enforcement action in line with CQC’s published enforcement policy. The Decision Tree is the judgment framework tool used to determine the seriousness of breaches of Regulations, and to determine the appropriate regulatory action CQC should take, in accordance with CQC’s published Enforcement Policy. Additionally, the CQC publish our findings which includes ratings.

Devon Partnership Trust (DPT) were the responsible Commissioner for Mr Glenn MacMartin’s care and support, and for the ongoing review of the quality of that care and support. The CQC have undertaken an internal review of the actions taken by CQC in relation to Annette’s Care Limited and in relation to the care provided to Glenn MacMartin. On the basis of that internal review CQC is satisfied its actions were taken in line with CQC methodology, were timely, justified and proportionate. In line with our information sharing and safeguarding procedures those actions included raising individual safeguarding alerts with Plymouth Adult Safeguarding which is the lead agency for adult safeguarding under the Care Act 2014. The CQC are participating in a ‘learning event’ with Devon and Cornwall Police, Devon Partnership Trust and Plymouth County Council (Commissioning and Adult Safeguarding) as part of our continuing effort to improve coordination of CQC and Local Authority actions, and to learn any relevant lessons, individually and/or collectively. Following the conclusion of the learning event we will consider any recommendations. Unfortunately, the family have not been available to participate which has had an impact on the progress of the learning event. We look forward to meeting with the family when they are available.

Review what actions are taken when care homes are closed to ensure lessons are learnt from such closures. In line with the CQC’s enforcement policy, civil enforcement action was taken and CQC issued a Notice of Proposal (NOP) to cancel the providers registration on 23 April 2019. The Registered Provider submitted representations to the CQC to appeal the proposal to cancel registration. The written representations were not upheld and the Notice of Decision (NOD) was served on 23 August 2019. The Registered Provider appealed to the First Tier Tribunal (Care Standards) in October 2019. Their appeal was refused and did not proceed to a hearing because it was out of time. The cancellation of the provider’s registration took effect on 28 February 2020. As part of the internal review undertaken in this case, CQC considered whether it revealed areas for improvement in CQC’s monitoring, inspection and/or enforcement methodology. We determined that the case did not reveal gaps or areas for improvement and that CQC’s actions were timely, justified and proportionate. In particular, partner agencies (Local Authority and Commissioners) made the necessary contingency arrangements to find residents living at Annette’s Care alternative homes; during this process the CQC worked closely with our partner agencies. CQC seeks to continually improve monitoring, coordination and the sharing of information with Local Authority and Commissioners. In relation to this case, CQC will participate with the ‘learning event’ taking place with the local authority and Devon Partnership Trust.

Once the learning event has taken place and any recommendations or learning has been identified and agreed, we would be delighted to share such recommendations and learning with HM Coroner Arrow.

Signed

Head of Inspection Adult Social Care, South Network

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OFFICIAL Strategic Priorities: Partnership Engagement Learning Assurance Plymouth Adult Safeguarding Partnership

Report to PSAP

Date
09.06.21 Name

Agency NHS Devon CCG; Chair of SAR sub group Report subject SAR sub group recommendation Strategic Plan ref: N/A SAB Sub-Group SAR

Purpose of report: To provide a recommendation to the Plymouth Safeguarding Adults Partnership (PSAP) following a referral for a Safeguarding Adult Review (SAR) Content:

Context: Once in receipt of a referral, the purpose of the SAR sub-group is to review the information held by agencies and make a recommendation to the Independent Chair of the PSAP as to whether a SAR should be commissioned, in line with the Care Act 2014 statutory guidance and the SAR sub group policy. Decisions for referrals must gain the support of a majority of the SAR sub-group members. Should they not be able to reach a majority decision, reasons for not agreeing are recorded and the decision referred to the PSAP Chair. In the event of the referral for a SAR not progressing, the SAR Sub-group will ensure the reasons will be recorded in writing, decision shared with the referrer and other stakeholders as appropriate. In addition, the SAR Sub-group may make alternative recommendations to the referrer.

Referral for Glenn MacMartin: The NHS Devon Clinical Commissioning Group (CCG) was asked to chair the group for this referral in order to provide independence for the decision process, as both the usual chair of the SAR subgroup and Devon and Cornwall Police had been involved in the Coronial process.

The SAR sub-group received a referral in respect of Mr MacMartin, and the Chair can confirm that 2 sub-group meetings were held to discuss in depth the relevant information. All 3 statutory partners were represented, Plymouth County Council, NHS Devon CCG and Devon

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OFFICIAL Strategic Priorities: Partnership Engagement Learning Assurance and Cornwall Police; therefore the meeting was quorate, and the decision unanimous.

Following review of all of the relevant information, it was agreed by the SAR subgroup that this referral did not meet the criteria for a SAR for the reasons stated below:  There was evidence of good multi-agency working in order to protect the adult with care and support needs, though there were some gaps in communication identified.  The events prior to Mr MacMartin’s death were thoroughly investigated by Devon & Cornwall Police, who found no evidence of a crime or abuse or neglect. This was reviewed and all agreed with the decision made by the police.  All safeguarding concerns and enquiries raised prior to Mr MacMartin’s death were reviewed and the group concurred with there being no abuse or neglect identified in them.  The whole service concern process regarding the care home in which he resided was reviewed, and it was clarified that whilst the parallel CQC process resulted in the home later being closed, this was a result of the lack of ability to comply with the requirements of the process, rather than any indication of neglectful care.  There was evidence that his care provider sought appropriate medical support in the days leading up to Mr MacMartin being admitted to hospital.  There was evidence of a timely and appropriate health response to the requests from the care home for a health assessment.  After his initial good response to treatment received in the hospital he sadly deteriorated and despite all their efforts to treat him, he very sadly passed away.  The pathologist’s report does not indicate any signs of abuse or neglect.  The group acknowledged there was a lack of communication between the care home and Mr MacMartin’s family.

While the recommendation is that a SAR is not the appropriate response to this referral, there is recognition of an opportunity for learning and this will be taken forward as a multi-agency response to the HMCO Regulation 28 request.

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OFFICIAL Strategic Priorities: Partnership Engagement Learning Assurance Formal response from PSAP Independent Chair Following the initial discussions at the PSAP Executive Group meeting on 1 June 2021, I have now received the SAR referral decision for the case of Mr Glenn MacMartin. I note the recommendation of the SAR sub group, under the Chair of , not to commission a SAR process. This decision was based on a full and thorough multi-agency analysis of the circumstances and contextual factors surrounding Mr MacMartin’s death, including a police investigation and post mortem examination.

I endorse the recommendation not to proceed to a SAR process based on the detailed rationale set out above. However, I fully support the commissioning of a multi-agency learning review, independently facilitated, to ensure that multi-agency learning is identified in terms of strengths and weaknesses, and subsequently translated into improved ways of working across the system. This should be a transparent process involving the engagement and participation of Mr MacMartin’s family, with the learning shared as widely as possible.

I understand that planning for the learning review is underway, and the following details of this will be communicated to Mr MacMartin’s family and to HMCO as the response to the Regulation 28 request.  Inform relevant partner agencies of the proposal, and secure engagement  Agree Terms of Reference and scope with partners  Identify and commission an independent facilitator (IF)  IF to set out plan to family, accept questions, parameters etc  IF meet before and after with family  Capture learning/record, feedback, report to the Coroner  Share learning

Independent Chair Plymouth Safeguarding Adults Partnership