_ My Narrative Conclusion as expanded in my summing up detailed a umber of failings the majority contributing to Doreen's death The outstanding concerns which would like each of the recipients where designated to consider which are listed below in no order of severity or importance are as follows:- a) (Wiltshire Council) When Doreen was admitted to hospital on 20th December 2015 the paramedics made a safeguarding referral to Wiltshire Council: Due to the fact that the admission took place on Sunday the referral fax was sent to the Emergency Out of Hours Team. was satisfied having heard a copy of the recording that South Western Ambulance Service also followed up that fax with a telephone call to the Emergency Sevices Team who confirmed that the fax had been received: It appears that in triaging the referral that it was signed off on the basis that Doreen had been admitted to The Great Western Hospital heard evidence from a Senior Adult Safeguarding Manager at Wiltshire Council, who confirmed my suspicion that in relation to the self-neglect issues that they would ordinarily have been left for the team at Athelston House to address as that from a common sense point of view would be the most appropriate way forward There however remained the issue as regards the possible financial abuse by Carer of Doreen: am concerned here as regards the procedures in place to ensure that safeguarding referrals are properly investigated and whilst was satisfied that what happened here did not contribute to Doreen's death am concerned that a safeguarding issue was not followed up and in fact was signed off in circumstances when clearly it should not have been. would like you to look into this matter with a view to reviewing what went wrong and providing assurances as regards what measures may be introduced to minimise the risk of this happening again in the future or if no action is proposed to be taken, why no action is to be taken; b) (Great Western Hospital) In considering the evidence when Doreen was discharged from The Great Western Hospital initially on the 21st December 2015, she was sent with discharge letter and page Medivo Summary summarising the paramedics' attendance on the 20th December 2015. Of note that summary did not contain any information that the paramedic had undertaken a 6CIT Cognitive evaluation of Doreen and that she had failed that assessment: One can never guarantee that another document will reflect the information contained in the initial report and therefore possible way forward could be to ensure in cases where the turnaround through hospital is short that as part of the Discharge Package that it includes a copy of the Paramedic handwritten report that would have been provide to Great Western Hospital when she was admitted. It is however for you to consider how to resolve the concern here that an important bit of information was not provided to the team at Athelston House; c) (Wiltshire Council; Wiltshire Health & Care and Great Western Hospital) As general comment; my view in relation to the quality and substance of case notes was that were poor in quality: My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen's therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available_ Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different concerns remain: Crucial and important decisions did not contain any rationale as to why and the_basis_upon_which that_decision_was_being_made As indicated when Tel 01722 438900 Fax 01722 332223 The and they my summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision made_ also have concerns in relation to the way MDT's work and reach decisions_ The decisions very much appear to be a consensual decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members_ There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen's case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions taken. d) (Wiltshire Health & Care) As of the evidence heard that Doreen in the opinion of an Expert Geriatric Psychiatrist, not only had a mental impairment (cognitive impairment more likely with underlying dementia) but also more importantly that in relation to serious and complex decision to return home she was of the view, in respect of which accepted, that more likely than not Doreen could not understand her needs and was unable to recognise the risk of refusing the safeguarding recommendations and that in relation to her decision to return home and those associated decisions that she did not have mental capacity: indicated in my summing up that this was a difficult case but feel that the training given especially to the Therapy led members of the team did not sufficiently prepare them to deal with very complicated cases such as Doreen's although that having been said if the advice that had been given had been followed the outcome possibly would have been different: was however satisfied that had the advice been followed and a capacity test undertaken that Doreen would not have returned home when she did therefore would not have died when she did. It was_also_readily apparent to me that members of the Therapy Led Team and particularly was unaware that the safeguarding measures, part of the Mental Capacity Act and in particular the ability to secure either and urgent or standard authorisation for the deprivation of somebody's liberty was not available where the individual concerned lives in the community where their care is paid for privately. As one witness said those cases can be extremely challenging and essentially those trying to do their best for the individual essentially have to wait for the next crisis to occur before they may be given an opportunity to introduce safeguarding measures_ Had the mental impairment been recognised and the mental capacity assessment been carried out revealing that she did not have mental capacity in relation to the serious and complex decision to return home and associated decisions concerning additional safeguarding measures and if Doreen still wished to return home then it may have been in her best interests to have considered Deprivation of Liberty Safeguarding Order_ would hope that this particular case in particular could be used as specific training case by all organisations involved but have concerns that there were material gaps in individuals' knowledge bases e) (Wiltshire Health & Care) Having commenced Coronial Investigation tasked Coroners Officers to make a number of enquiries on my behalf and that included securing statements As part of documentation that was disclosed by Wiltshire Health and Care was an email from Intermediate Care Lead Carol Langley-Johnson; her email sent to Acting Coroner's Officer bn 4th July 2016 contained a final paragraph that said 1 have no concern about the standards of care provided by my team, have read their statements and feel that this is a fair representation of rehab she received"' As will have been abundantly clear from reading this report and my Narrative Conclusion did not share the same view as Ms Langley-Johnson and am concerned and surprised that prior to the Inquest Final Hearing that no attempt was undertaken to carry out any form of Serious Case Review by Wiltshire Health and Care, formerly Great Western Hospital: am concerned as regards the system in place that will pick up serious incidents for review and the mechanism in place to undertake investigations with a view to learning points being highlighted, the consideration of procedural changes and the implementation of any changes including additional training needs where required. am concerned that there_may be other incidences_where there are learning where Wiltshire & Swindon Coroner's Office, 26 Endless Street, Salisbury; Wiltshire, SP1 1DP Tel 01722 438900 Fax 01722 332223 being being part and and points there has not been a review and whilst those incidents may not have resulted in the death of an individual that the learning points have not been recognised and therefore there is the potential out there for repetition and in extreme circumstances repetition of dangerous practices that may lead t0 death and the involvement of me and my office would ask respectfully that those recipients of this letter where indicated in brackets consider concerns raised and deal with them