Dear Mr Osborne Inquest touching the death of_Mergaret _Emily_Elemming Thank you for your letter dated 30h January 2015. will respond to the concems In Section 5 'Coroners Concems' of your Regulation 28 Report in turn: Deprivation of Llberty Safeguards (DoLS): Urgent and standard acthorisation requests were received by the Council from Carrington Hlouse care home on &" October 2014, The reason for the requests was that Mrs Flemming lacked the option to leave care setting and required continuous supervision and control You expressed your concern that the Best Interests Assessment did not Itake place until 7t January 2015 and you feit that the deceased remained vulnerable during this Since March 2014, the Council has adopted risk based approach prioritising DoLS assessments on the basis of risk Of harm tocthe person concemed _ and using & waiting list for those assossed as low risk: As there was no indication of concern with Mrs Flemming's care package. no concerns raised by her family, and no indication of undue or excessive physical or medical restraint being used the roquest relating to Mrs Flemming was assessed as Jow risk Because of this, it meant that Mrs Flemming' s Best Interests Assessment did not take place until gth January 2015. The outcome of this wae that restrictions amounting to continuous supervision and control had been in place for frequent and prolonged periods since Mrs Flerming'$ admission on 2009 , she was not free to leave, and the placement Was in her best interests. No changes to the care plan (conditions) were recommended as result of the assessment_ Contiz_ Ceniral 8 kurdslics Couacl: Priory House, Morks Walk Telephone 0300 300 8000 Chicksands, Shefford Email customer services @centralbedfordshire govuk Bedfardshire SG17 5TQ WW_ centralbedfordshire gov uk the time 22nd May

2 2, Whilst the Council acknowledges that Mrs Flemming did not receive a DoLs assessment within the timescales prescribed by law_ we are satisfied that the care being provided fo her during that tirne was appropriate and in her best interests, An annual review of her care package had been conducted by a social worker on September 2014 and Best Interests Assessment on gth January 2015 During this period there were no reports to the Council that the care home was unable to meet Mrs Flemming's needs_ Tha Council has adopted the prioritisation approach ad waiting list as temporary measure, in order to be able to respond to the ten fold increase in DoLS activily. Part of the strategy to respond to this increase has been to recruit temporary qualified staff, and train additional steff t0 perform the Best Interests Assessor function_ The Council is maintaining Its investment in these staff to deal with the increase in activity. Whilst the waiting list Is reducing (from 237 In January to 209 In February) thls is not & position the Council wishes to maintain: We are currently in the process of] procuring extemal specialist support to undertake all of the assessments on tha waitirig [ist: If you wish to discuss this matter furtherplease contac Director pf Social Care Health and Housing and Head of Quality Improvement & Safeguarding think it would be helpful for there to be a discussion about your comments that action should be taken to prevent future deaths: It would appear that Mrs Flemming' $ death was due to bronchopneumonia and End Stage Senile Derentia: