Russell Robb
PFD Report
All Responded
Ref: 2017-0385
All 1 response received
· Deadline: 16 Feb 2018
Coroner's Concerns (AI summary)
A lack of regular medication reviews and guidelines on drug quantities, coupled with limited information sharing between safeguarding bodies, meant significant police interactions with the deceased were missed, hindering appropriate strategic oversight.
View full coroner's concerns
In the circumstances it is my statutor duty to report to you: along which ultimately led to his death: There was no evidence of regular reviews of his medication: There appeared to be no guidelines in place to reduce the quantity of available to Mr Robb at any one time: (CCG; Secretary of State for Health) There was limited evidence of information sharing between the members of the Trafford Adult Safeguarding Board. This meant that the Local Authority were unaware of the volume of interaction between the Police and Mr Robb (Adult Safeguarding Board) As a result only 1 strategic meeting took place over a 6 year period
Responses
Action Taken
Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is attached. (AI summary)
Greater Manchester Police (GMP) now record high volume callers more accurately, and the GMP function that prioritises and allocates cases now sits within the Partnership Office. A revised policy is attached. (AI summary)
View full response
Dear Ms Mutch, Re: RCR am writing to you further to your correspondence of 21st December 2017.Firstly would like to apologise for the delay in replying: At paragraph 5.2 you raised as Matter of Concern the limited evidence of information sharing between the partners of Trafford Safeguarding Adults Board and in response would like to share the following information: In terms of what action has been taken to improve practice in Trafford, Greater Manchester Police (GMP) now record high volume callers more accurately, identifying those that come into contact with the police more readily, thereby enabling earlier identification of individuals with complex needs and communication of these concerns with the Local Authority: The GMP function that prioritises and allocates cases in Trafford now sits within the Partnership Office at Stretford Police Station co-located with the Anti-Social Behaviour Team and neighbourhood police teams to enable more effective problem solving and decision making at lower levels of concern: From mid-February 2018, more complex individuals will be discussed at daily vulnerable adult meetings between relevant Detective Sergeant at GMP and Local Authority social care managers. There are also advanced plans in place which will lead to a number of GMP staff being CO- located at Trafford Town Hall to work alongside health and social care colleagues to support better communication and joined-up approach in responding to concerns about vulnerable individuals who come into contact with services. In the meantime, GMP's Public Protection Investigation Unit has relocated from Altrincham to Stretford Police Station, next door to Trafford Town Hall, making face-to-face meetings and communication easier to facilitate The adult social care Screening Team relocated to Trafford Town Hall in December 2016 to sit alongside its children's social care equivalent and our health safeguarding colleagues_ This has helped us to share information more quickly ad provide more effective, all-age responses to safeguarding concerns_ We have updated the Terms of Reference of our TARGet (Trafford Adults at Risk Group) meeting to facilitate better information sharing between safeguarding partners and improve multi-agency risk assessment and risk management planning with regard to supporting the
adults at ongoing risk of harm: We now have a more robust and effective process in The revised policy is attached: Section 42 within the Care Act 2014 formally recognises self-neglect as a category of abuse and neglect Trafford has responded to the most recent change in legislation by developing specific, relevant multi agency training and the first session is due t0 commence on 26th March 2018. Trafford had launched more generic multi-agency safeguarding training in early 2017 . At strategic level, we are in the process of redesigning our Safeguarding Boards and developing a more effective, integrated children and adults structure, whilst ensuring that a unique focus on each group is retained_ We now have an all age integrated health and social care structure to deliver community services in Trafford, facilitated by a Section 75 agreement between Trafford Council and Pennine Care NHS Foundation Trust This has enhanced our ability to look at whole family approaches to address needs and concerns and made information sharing between health and social care staff more straightforward_ We will monitor and regularly review all new arrangements and processes to ensure that they have led to the desired improvement in practice_ hope that this information offers sufficient reassurance that the appropriate action is being taken in response to the issues raised. Please do not hesitate to contact me if you require any further information:
adults at ongoing risk of harm: We now have a more robust and effective process in The revised policy is attached: Section 42 within the Care Act 2014 formally recognises self-neglect as a category of abuse and neglect Trafford has responded to the most recent change in legislation by developing specific, relevant multi agency training and the first session is due t0 commence on 26th March 2018. Trafford had launched more generic multi-agency safeguarding training in early 2017 . At strategic level, we are in the process of redesigning our Safeguarding Boards and developing a more effective, integrated children and adults structure, whilst ensuring that a unique focus on each group is retained_ We now have an all age integrated health and social care structure to deliver community services in Trafford, facilitated by a Section 75 agreement between Trafford Council and Pennine Care NHS Foundation Trust This has enhanced our ability to look at whole family approaches to address needs and concerns and made information sharing between health and social care staff more straightforward_ We will monitor and regularly review all new arrangements and processes to ensure that they have led to the desired improvement in practice_ hope that this information offers sufficient reassurance that the appropriate action is being taken in response to the issues raised. Please do not hesitate to contact me if you require any further information:
Sent To
- Trafford Clinical Commissioning Group
Response Status
Linked responses
1 of 2
56-Day Deadline
16 Feb 2018
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
On 18th April 2016 commenced an investigation into the death of Russell Charles ROBB. The investigation concluded on the 24th November 2017 and the conclusion of the jury was narrative: Mr Robb did not intend the outcome to be fatal: Mr Robb had taken a fatal combination of prescribed and non-prescribed drugs, mixed with alcohol: Due to Mr Robb's vulnerable mental state along with his level of intoxication, it is more likely than not that Mr Robb was unaware of the high level of substances that he consumed. Mr Robb displayed very anxious, aggressive and erratic behaviour, which were heightened after receiving a letter regarding his benefits. In the past, it is evident that there was a lack of communication between multiple agencies along with the fact that Mr Robb failed to comply and engage with professional help: There was inadequate monitoring of Mr Robb's administration of prescribed drugs The medical cause of death was 1a Combined Drug Toxicity; and 2 Ischaemic Heart Disease Mr Robb died on 9th April 2016 at 20.27pm at Manchester Royal Infirmary. Mr Robb had taken a cocktail of drugs (prescribed and non-prescribed) with a substantial amount of alcohol prior to his death During the early evening of gth April 2016,Police officers forced entry to Mr Robb's property, discovering him in a collapsed state. CPR was administered by both Police Constables, the ambulance and fire service attended: The fire service attempted to resuscitate using a defibrillator. Mr Robb was transferred to A&E at Manchester Royal Infirmary, where further means of resuscitation took place: At 20.27pm, Mr Robb was pronounced dead.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.