Avis Addison
PFD Report
All Responded
Ref: 2020-0216
All 1 response received
· Deadline: 2 Feb 2021
Coroner's Concerns (AI summary)
Concerns about ensuring GP practices have robust domestic violence and safeguarding policies/training, and implementing "early warning systems" for suspicious missed appointments or uncollected prescriptions.
View full coroner's concerns
I am concerned to ensure that the lessons from this and previous tragedies are learned and robust checks are made to prevent future deaths from happening.
Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place, and to ensure that all staff have received training on their contents, is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part of the process.
Another matter that you may feel would be beneficial to inspect is whether practices have in place some form of ‘early warning system’ where, for example, prescriptions are not collected or appointments are cancelled without good reason (eg by a controlling partner.)
I accept this may be more difficult to do in non-prescribing practices but with clear guidance I would hope that it may still be possible to achieve.
Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place, and to ensure that all staff have received training on their contents, is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part of the process.
Another matter that you may feel would be beneficial to inspect is whether practices have in place some form of ‘early warning system’ where, for example, prescriptions are not collected or appointments are cancelled without good reason (eg by a controlling partner.)
I accept this may be more difficult to do in non-prescribing practices but with clear guidance I would hope that it may still be possible to achieve.
Responses
Action Taken
Following the regulation 28 notice, CQC contacted the registered person of the GP practice, and were assured about the management of safeguarding and vulnerable patients; learning from the inquest will be shared with inspectors. (AI summary)
Following the regulation 28 notice, CQC contacted the registered person of the GP practice, and were assured about the management of safeguarding and vulnerable patients; learning from the inquest will be shared with inspectors. (AI summary)
View full response
Dear HM Senior Coroner
Prevention of future deaths report following the Inquest into the death of Avis Mary Addison Thank you for your Regulation 28 report to prevent future deaths issued following the inquest into the sad death of Avis Mary Addison.
The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to inspect whether or not the fundamental standards are being met. The legislation that governs this function is The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
In the regulation 28 report, you have asked CQC to consider the following concerns:
Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place, and to ensure that all staff have received training on their contents, is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part of the process.
CQC do not always routinely check all training records as part of an inspection. This will depend on the service; the type of inspection and what concerns have been raised.
All providers must comply with the regulations as set out in The Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. Regulation 12 (Safe care and treatment) requires providers to assess the risks to people's health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. This would HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Telephone:
Fax: 03000 616171
2
include how to recognise when vulnerable patients failed to attend appointments or collect prescriptions. Regulation 13 (Safeguarding service users from abuse and improper treatment) includes ensuring systems (policies) and processes were established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of abuse.
A provider’s compliance with the regulations will be assessed at inspection. As part of a CQC comprehensive inspection the practice will be inspected against five key questions, whether a service is safe, effective, caring, responsive and well led. Each of the five key questions are broken down into a further set of questions, the key lines of enquiry (KLOEs). When CQC inspects, these are used to help CQC decide what the inspection needs to focus on. For example, the inspection team might look at how risks are identified and managed to help them understand whether a service is safe. As part of the consideration as to whether a service is safe, CQC will consider how systems, processes and practices keep people safe and safeguarded from abuse, how these are monitored and improved and whether staff receive effective training in safety systems, processes and practices.
CQC does not provide a list of mandatory training expected members of the GP practice team. This is because training requirements will depend on the role and specific responsibilities of practices, and the needs of the people using the service. Ultimately, the practice is responsible for determining what mandatory and additional training staff need and how this is delivered. Although there is no definitive list of mandatory training. Examples of training CQC would expect to see evidence of include training to the appropriate level on safeguarding adults at risk and safeguarding children.
(ii) Another matter that you may feel would be beneficial to inspect is whether practices have in place some form of ‘early warning system’ where, for example, prescriptions are not collected or appointments are cancelled without good reason (e.g. by a controlling partner.)
CQC will consider as part of the inspection of a practice, the systems in place to support the management of vulnerable patients. This includes a review of the process to manage where patient prescriptions have not been collected or appointments are not attended.
In 2018, an additional prompt was added to the KLOEs, namely “is there a system to highlight vulnerable patients on records e.g. children living in care or in houses with domestic violence, young carers, substance misuse, siblings of children on child protection plans, people who have experienced domestic abuse, adults and children with high numbers of A&E and/or urgent care attendances, female genital mutilation (FGM) victims, refugees, patients diagnosed with mental health, patients with severe mental illness (SMI) or patients with mobility issues? Is there a risk register of specific patients e.g. SMI Register?” The prompt is to check as part of the inspection, that there is a system in place to ensure vulnerable patients are
3
safe and checks are undertaken, that a provider has flags on the system to highlight a vulnerable patient and if something untoward occurs they are identified, and timely action is considered.
The Royal College of Nursing published their Intercollegiate guidance on Adult Safeguarding: Roles and Competencies for Health Care Staff in August 2018. This set out the competencies, knowledge and skills expected to support adult safeguarding, including domestic abuse. This includes ensuring staff are familiar with the relevant associated legislation and guidance, including; domestic abuse and domestic homicide. CQC responded to this updated guidance by publishing further information for inspectors and providers on safeguarding roles, competencies and functions relating to safeguarding.
We are currently now in a period of consultation about our next steps of regulation. During this time, we will continually keep our scope of regulation under review and update our regulatory approaches frequently. This will include strengthening how we regulate safeguarding in the future.
We continue to respond to risk during this consultation period, including concerns and issues raised in this report.
CQC Regulatory Action:
CQC undertook an inspection in March 2019 at the GP practice where Avis Addison was registered as a patient. This inspection was undertaken after the death of Mrs Addison. There were no areas of concern in relation to the relevant practice policies, staff understanding, training and systems to support the management of vulnerable patients in the practice
Following receipt of the regulation 28 notice, CQC made contact with the registered person of the GP practice where Mrs Addison was registered. This was to request information in relation to the changes made by the practice in process and policy following the inquest and any subsequent updates and training received by the GP. From the information CQC received from the provider, we were satisfied and assured about the management of safeguarding and vulnerable patients in the practice, which demonstrates how they are ensuring people are safe and risks are mitigated.
Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Avis Addison with inspectors.
We hope that this response addresses your concerns. If this is not the case, please could you clarify any further details you require.
4
Prevention of future deaths report following the Inquest into the death of Avis Mary Addison Thank you for your Regulation 28 report to prevent future deaths issued following the inquest into the sad death of Avis Mary Addison.
The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to inspect whether or not the fundamental standards are being met. The legislation that governs this function is The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
In the regulation 28 report, you have asked CQC to consider the following concerns:
Given CQC is the agency responsible for inspection of GP practices, one way to ensure GP practices have domestic violence and safeguarding policies in place, and to ensure that all staff have received training on their contents, is to include checks in this regard as part of your inspection regime. It is, of course, entirely possible that this is already part of the process.
CQC do not always routinely check all training records as part of an inspection. This will depend on the service; the type of inspection and what concerns have been raised.
All providers must comply with the regulations as set out in The Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. Regulation 12 (Safe care and treatment) requires providers to assess the risks to people's health and safety during any care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe. This would HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Telephone:
Fax: 03000 616171
2
include how to recognise when vulnerable patients failed to attend appointments or collect prescriptions. Regulation 13 (Safeguarding service users from abuse and improper treatment) includes ensuring systems (policies) and processes were established and operated effectively to investigate, immediately upon becoming aware of, any allegation or evidence of abuse.
A provider’s compliance with the regulations will be assessed at inspection. As part of a CQC comprehensive inspection the practice will be inspected against five key questions, whether a service is safe, effective, caring, responsive and well led. Each of the five key questions are broken down into a further set of questions, the key lines of enquiry (KLOEs). When CQC inspects, these are used to help CQC decide what the inspection needs to focus on. For example, the inspection team might look at how risks are identified and managed to help them understand whether a service is safe. As part of the consideration as to whether a service is safe, CQC will consider how systems, processes and practices keep people safe and safeguarded from abuse, how these are monitored and improved and whether staff receive effective training in safety systems, processes and practices.
CQC does not provide a list of mandatory training expected members of the GP practice team. This is because training requirements will depend on the role and specific responsibilities of practices, and the needs of the people using the service. Ultimately, the practice is responsible for determining what mandatory and additional training staff need and how this is delivered. Although there is no definitive list of mandatory training. Examples of training CQC would expect to see evidence of include training to the appropriate level on safeguarding adults at risk and safeguarding children.
(ii) Another matter that you may feel would be beneficial to inspect is whether practices have in place some form of ‘early warning system’ where, for example, prescriptions are not collected or appointments are cancelled without good reason (e.g. by a controlling partner.)
CQC will consider as part of the inspection of a practice, the systems in place to support the management of vulnerable patients. This includes a review of the process to manage where patient prescriptions have not been collected or appointments are not attended.
In 2018, an additional prompt was added to the KLOEs, namely “is there a system to highlight vulnerable patients on records e.g. children living in care or in houses with domestic violence, young carers, substance misuse, siblings of children on child protection plans, people who have experienced domestic abuse, adults and children with high numbers of A&E and/or urgent care attendances, female genital mutilation (FGM) victims, refugees, patients diagnosed with mental health, patients with severe mental illness (SMI) or patients with mobility issues? Is there a risk register of specific patients e.g. SMI Register?” The prompt is to check as part of the inspection, that there is a system in place to ensure vulnerable patients are
3
safe and checks are undertaken, that a provider has flags on the system to highlight a vulnerable patient and if something untoward occurs they are identified, and timely action is considered.
The Royal College of Nursing published their Intercollegiate guidance on Adult Safeguarding: Roles and Competencies for Health Care Staff in August 2018. This set out the competencies, knowledge and skills expected to support adult safeguarding, including domestic abuse. This includes ensuring staff are familiar with the relevant associated legislation and guidance, including; domestic abuse and domestic homicide. CQC responded to this updated guidance by publishing further information for inspectors and providers on safeguarding roles, competencies and functions relating to safeguarding.
We are currently now in a period of consultation about our next steps of regulation. During this time, we will continually keep our scope of regulation under review and update our regulatory approaches frequently. This will include strengthening how we regulate safeguarding in the future.
We continue to respond to risk during this consultation period, including concerns and issues raised in this report.
CQC Regulatory Action:
CQC undertook an inspection in March 2019 at the GP practice where Avis Addison was registered as a patient. This inspection was undertaken after the death of Mrs Addison. There were no areas of concern in relation to the relevant practice policies, staff understanding, training and systems to support the management of vulnerable patients in the practice
Following receipt of the regulation 28 notice, CQC made contact with the registered person of the GP practice where Mrs Addison was registered. This was to request information in relation to the changes made by the practice in process and policy following the inquest and any subsequent updates and training received by the GP. From the information CQC received from the provider, we were satisfied and assured about the management of safeguarding and vulnerable patients in the practice, which demonstrates how they are ensuring people are safe and risks are mitigated.
Where CQC identifies that regulations are not being met, we use our enforcement powers to require improvements to be made. We continue to do this and will share key learning and practice points from the inquest into the death of Avis Addison with inspectors.
We hope that this response addresses your concerns. If this is not the case, please could you clarify any further details you require.
4
Sent To
- Care Quality Commission
Response Status
Linked responses
1 of 1
56-Day Deadline
2 Feb 2021
All responses received
About PFD responses
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 14/10/20, I concluded an inquest into the death of Avis Mary Addison who died on 22/2/17. . The medical cause of death was recorded as: 1a) Suffocation 1b) 1c) II) Alzheimer's Dementia, Frailty of Old Age and Multiple Blunt Force Injuries
I recorded a Conclusion of Unlawful Killing.
I recorded a Conclusion of Unlawful Killing.
Circumstances of the Death
The tragic circumstances behind Mrs Addison’s murder at the hands of her late husband have been the subject of a joint Safeguarding/Domestic Homicide Review (DHR 7.) A copy of the updated DHR overview report (dated 11/19) is attached.
When I first reviewed this matter, I was concerned to ascertain whether there was sufficient reason to resume the inquest after its adjournment to allow the criminal prosecution to take place. At a hearing with the Interested Persons (IPs) in April 2020, I concluded there was sufficient reason and identified the following central issues: a) Was there a failure or delay in recognising the potential for domestic abuse and/or violence?
b) Has the need for a domestic abuse/violence policy been circulated to all GP practices in the coroner area and has this been brought to the attention of practitioners? The views of NHS Kernow are required.
c) Has the need for domestic abuse/violence policies in primary care nationally been considered and, if appropriate, actioned? The views of NHS England are required.
d) Has there been a failure or delay in considering whether to conduct a Mental Capacity Act examination of Mrs Addison? The views of the GP and Social Worker are required.
e) Is there clarity in the process for raising a safeguarding concern? The view of Information Classification: CONTROLLED Adult Social Care is required.
f) Are Social Workers aware of the potential application of the provisions contained within the Care Act 2014? The view of Adult Social Care is required.
It is in relation to points b) and c) that I write to CQC. Of particular concern was that these issues had been recurring themes in earlier DHRs giving rise to the worry that lessons had not been learned from previous experiences.
Further evidence addressing those issues was obtained and I enclose copies of the letters I received from Mrs , Chief Officer for KCCG, dated 23/4/20 and Mrs , Assistant Director for Quality and Safeguarding, from NHS England (South-West) dated 9/6/20.
You will see the steps taken by NHS Kernow to ensure GP practices in Cornwall and the Isles of Scilly have appropriate Domestic Violence policies and Safeguarding Leads in place. You will also see that national recommendations were not able to be acted upon.
When I first reviewed this matter, I was concerned to ascertain whether there was sufficient reason to resume the inquest after its adjournment to allow the criminal prosecution to take place. At a hearing with the Interested Persons (IPs) in April 2020, I concluded there was sufficient reason and identified the following central issues: a) Was there a failure or delay in recognising the potential for domestic abuse and/or violence?
b) Has the need for a domestic abuse/violence policy been circulated to all GP practices in the coroner area and has this been brought to the attention of practitioners? The views of NHS Kernow are required.
c) Has the need for domestic abuse/violence policies in primary care nationally been considered and, if appropriate, actioned? The views of NHS England are required.
d) Has there been a failure or delay in considering whether to conduct a Mental Capacity Act examination of Mrs Addison? The views of the GP and Social Worker are required.
e) Is there clarity in the process for raising a safeguarding concern? The view of Information Classification: CONTROLLED Adult Social Care is required.
f) Are Social Workers aware of the potential application of the provisions contained within the Care Act 2014? The view of Adult Social Care is required.
It is in relation to points b) and c) that I write to CQC. Of particular concern was that these issues had been recurring themes in earlier DHRs giving rise to the worry that lessons had not been learned from previous experiences.
Further evidence addressing those issues was obtained and I enclose copies of the letters I received from Mrs , Chief Officer for KCCG, dated 23/4/20 and Mrs , Assistant Director for Quality and Safeguarding, from NHS England (South-West) dated 9/6/20.
You will see the steps taken by NHS Kernow to ensure GP practices in Cornwall and the Isles of Scilly have appropriate Domestic Violence policies and Safeguarding Leads in place. You will also see that national recommendations were not able to be acted upon.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.