Gloria Foster
PFD Report
Partially Responded
Ref: 2014-0399
Coroner's Concerns (AI summary)
Insufficient protocols for staff support and training during care provider closures, unclear team leader supervision, and poor management of communication channels with closed providers created risks.
View full coroner's concerns
During the course of the inquest the evidence revealed matters that gave rise to concerns that circumstances creating a risk of other deaths will continue to exist in the future unless action is taken.
1. The need to have a protocol relating to the provision of additional support for operational staff when the need to prioritise work surrounding the closure of a care provider arises.
2. The need for additional specific training to reinforce to staff the apparent dangers of taking a different attitude to the needs of MS4269 2 Rtdoc/00464‐2013/Reg28/23.10.2014
MS4269 3 Rtdoc/00464‐2013/Reg28/23.10.2014
3. The need for additional specific training to ensure that there is a clear understanding of the role of Team Leader in relation to the supervision of tasks delegated by them to other members of their team.
4. The need to ensure that when a care provider is closed, all lines of communication with that provider, including telephone and email, are managed so that anyone who uses any one of those lines to make contact with them is immediately informed of the current situation and of where to go to seek advice or help.
1. The need to have a protocol relating to the provision of additional support for operational staff when the need to prioritise work surrounding the closure of a care provider arises.
2. The need for additional specific training to reinforce to staff the apparent dangers of taking a different attitude to the needs of MS4269 2 Rtdoc/00464‐2013/Reg28/23.10.2014
MS4269 3 Rtdoc/00464‐2013/Reg28/23.10.2014
3. The need for additional specific training to ensure that there is a clear understanding of the role of Team Leader in relation to the supervision of tasks delegated by them to other members of their team.
4. The need to ensure that when a care provider is closed, all lines of communication with that provider, including telephone and email, are managed so that anyone who uses any one of those lines to make contact with them is immediately informed of the current situation and of where to go to seek advice or help.
Responses
Noted
The CQC acknowledges the concerns and explains its role in regulating care providers. They note that the Local Authority is responsible for managing communication lines when a provider closes and suggest they work with ADASS to address the issue nationally. The CQC is undertaking a review to ensure information from Regulation 28 reports is systematically integrated into their processes. (AI summary)
The CQC acknowledges the concerns and explains its role in regulating care providers. They note that the Local Authority is responsible for managing communication lines when a provider closes and suggest they work with ADASS to address the issue nationally. The CQC is undertaking a review to ensure information from Regulation 28 reports is systematically integrated into their processes. (AI summary)
View full response
Dear Mr Travers Thank you for your letter dated 10 September 2014 in which you wrote to us under the provisions of Regulation 28 of the Coroners (Investigations) Regulations 2013 ("the Regulations') in relation to the inquest into the death of Gloria Foster. We were extremely saddened to learn of the death of Ms Foster and of the circumstances leading to her death: We are also extremely grateful for your report in requiring us to review what actions should be taken to prevent the occurrence or continuation of such circumstances in the future_ Please treat this letter as the formal response of the Care Quality Commission (CQC') to your report dated 10 September 2014. We apologise for the delay in responding to your report. The delay has resulted from careful consideration being given from operational and policy perspectives of the CQC's response in operational and policy terms. In your report and pursuant to the requirements of Regulation 29 of the Regulations you require the CQC to provide details of any actions that it intends to take, or has taken to address the concerns highlighted in your report: In particular you required the CQC to consider the concerns outlined at paragraph 5(4) of your report as follows "The need to ensure that when care provider is closed, all lines of communication with that provider; including telephone and email, are managed so that anyone who uses any one of those lines to make contact with them is immediately informed of the current situation and of where to go to seek advice or help'
In drafting this response significant consideration and consultation has been given to your report by policy and operational teams. In particular we have considered what the current statutory framework empowers and obliges both the CQC and other relevant agencies to do in circumstances such as those that led to Mrs Foster's tragic death. The current statutory and regulatory framework does not confer on the CQC the duty or power to manage the lines of communication specifically in the way that you envisage. By contrast we understand that Local Authorities and Clinical Commissioning Groups (CCGs') do have such primary duties and powers Accordingly, those bodies are required to have sufficiently robust arrangements and procedures in place to ensure that they meet those duties without relying on third party agencies such as the CQC. The CQC does recognise the fundamental importance of notifying the relevant duty- holding agencies in circumstances where urgent cancellation is sought in order to avoid the possibility that circumstances such as those that led to the death of Ms Foster might arise_ The CQC also recognises that such cooperation and notification is crucial; For that reason, the CQC has clear guidelines on who must be informed when we urgently cancel provider's registration. Those guidelines were in place at the time of Ms Foster's death and were followed in this case We attach copy of the guidance, which includes sets out as follows in particular at paragraph 11: 611_ Do we need to inform anybody else that we have applied for an urgent cancellation of registration? Yes As soon as possible after an application has been made_ you must tell: The Clinical Commissioning Group in which area the regulated activity (RA) is being carried on, where the regulated activity to which the Order relates involves, or is connected with, the provision of health care, and to the NHS England Area Team in connection with primary medical or dental care. The local authority in whose area the regulated activity is being carried on, where the regulated activity to which the Order relates involves or is connected with the provision of social care_ Monitor; Where the regulated activity or service is carried on by an NHS foundation trust Or NHS Trust Development Authority, where the service provider is not currently an NHS foundation trust other people that we think are appropriate: For example the Department of Health may need to know if we decide to cancel the registration of an NHS provider: We do this by giving notice of the application by phone call, then following this up by sending the 'notifying others' letter: There are email and letter templates for this in CRM: Any
Note: For Notices of Proposal to cancel registration and Notices of Decision to cancel we would send a copy of the Notice. We note from its response that the Local Authority acknowledges that the responsibility for managing the lines of communication in this case with them. We also note that the Local Authority has undertaken to take steps to address the deficiencies that this incident highlighted. We respectfully suggest that it might be prudent for the Local Authority to seek to ensure that the same issues are addressed across all local authorities nationally by working with the Association of Directors of Adult Social Services (ADASS'). We greatly value the intelligence provided in your report and intend to address the concern raised at paragraph 5(4) in particular: The CQC is currently also undertaking detailed review designed to ensure that the valuable information provided by Regulation 28 reports, as well as from other sources of information, systematically and effectively into our intelligent monitoring, inspection and registration processes. We hope that this response addresses concerns raised in your report Please do not hesitate to contact us if we can be of any further assistance
In drafting this response significant consideration and consultation has been given to your report by policy and operational teams. In particular we have considered what the current statutory framework empowers and obliges both the CQC and other relevant agencies to do in circumstances such as those that led to Mrs Foster's tragic death. The current statutory and regulatory framework does not confer on the CQC the duty or power to manage the lines of communication specifically in the way that you envisage. By contrast we understand that Local Authorities and Clinical Commissioning Groups (CCGs') do have such primary duties and powers Accordingly, those bodies are required to have sufficiently robust arrangements and procedures in place to ensure that they meet those duties without relying on third party agencies such as the CQC. The CQC does recognise the fundamental importance of notifying the relevant duty- holding agencies in circumstances where urgent cancellation is sought in order to avoid the possibility that circumstances such as those that led to the death of Ms Foster might arise_ The CQC also recognises that such cooperation and notification is crucial; For that reason, the CQC has clear guidelines on who must be informed when we urgently cancel provider's registration. Those guidelines were in place at the time of Ms Foster's death and were followed in this case We attach copy of the guidance, which includes sets out as follows in particular at paragraph 11: 611_ Do we need to inform anybody else that we have applied for an urgent cancellation of registration? Yes As soon as possible after an application has been made_ you must tell: The Clinical Commissioning Group in which area the regulated activity (RA) is being carried on, where the regulated activity to which the Order relates involves, or is connected with, the provision of health care, and to the NHS England Area Team in connection with primary medical or dental care. The local authority in whose area the regulated activity is being carried on, where the regulated activity to which the Order relates involves or is connected with the provision of social care_ Monitor; Where the regulated activity or service is carried on by an NHS foundation trust Or NHS Trust Development Authority, where the service provider is not currently an NHS foundation trust other people that we think are appropriate: For example the Department of Health may need to know if we decide to cancel the registration of an NHS provider: We do this by giving notice of the application by phone call, then following this up by sending the 'notifying others' letter: There are email and letter templates for this in CRM: Any
Note: For Notices of Proposal to cancel registration and Notices of Decision to cancel we would send a copy of the Notice. We note from its response that the Local Authority acknowledges that the responsibility for managing the lines of communication in this case with them. We also note that the Local Authority has undertaken to take steps to address the deficiencies that this incident highlighted. We respectfully suggest that it might be prudent for the Local Authority to seek to ensure that the same issues are addressed across all local authorities nationally by working with the Association of Directors of Adult Social Services (ADASS'). We greatly value the intelligence provided in your report and intend to address the concern raised at paragraph 5(4) in particular: The CQC is currently also undertaking detailed review designed to ensure that the valuable information provided by Regulation 28 reports, as well as from other sources of information, systematically and effectively into our intelligent monitoring, inspection and registration processes. We hope that this response addresses concerns raised in your report Please do not hesitate to contact us if we can be of any further assistance
Sent To
- Care Quality Commission
- Surrey County Council
Response Status
Linked responses
1 of 2
56-Day Deadline
5 Nov 2014
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
The inquest into Mrs FOSTER’s death was opened on the 12th February 2013 and was resumed on 1st September 2014. It was concluded on 9th July 2014. The cause of death was: 1a. Pulmonary thromboembolism 1b. Deep venous thrombosis.
The conclusion was: Mrs Gloria Foster died from natural causes contributed to by neglect.
The conclusion was: Mrs Gloria Foster died from natural causes contributed to by neglect.
Circumstances of the Death
By January 2013 a decision had been taken by the Metropolitan Police and the UK Border Agency to close a care provider by the name of Carefirst 24 (‘the Company’). The closure was to be marked by a raid on the Company’s offices which was due to take place on the morning of the 15th January 2013. The Company provided care for, amongst others, some thirteen people in Surrey, one of whom was Mrs Foster. Surrey County Council (‘the Council’) were made aware of the pending closure. By MS4269 1 Rtdoc/00464‐2013/Reg28/23.10.2014
Friday 11th January 2013 the Council were aware of all but three of the service users whose care was provided by the Company and set about making alternative care arrangements for them. Following the raid the details of the remaining three service users were made available to the Council. All three of those remaining service users, who included Mrs Foster, were funding their care privately. By 13.00 hours on the 15th January 2013 Mrs Foster’s details, including the nature and the frequency of the care provided, namely four times per day, were known to the Banstead and Reigate Locality team, being the team within the Council with responsibility for organising an alternative care package on her behalf. In the event, nothing was done to arrange alternative care. Consequently, Mrs Foster was left on her own, incapable of looking after herself and with no care, for a period of nine days until she was discovered by a District Nurse. She was admitted to Epsom General Hospital very seriously ill and received treatment for a number of different problems including dehydration. Despite that treatment, she died on the 4th February 2013, whilst still at the hospital. The immobility and the dehydration from that nine day period was found to have made a material contribution to the cause of her death. No proper explanation was given by the Council for the failure to arrange suitable alternative care. The Banstead and Reigate Locality Team were under great pressure of work at the time and the Senior Operation Lead from that team, to whom the task of arranging suitable alternative care had been delegated, said that she had been influenced by the fact that Mrs Foster was a ‘self‐funder’. She went on to say that there is a bit of an assumption that self funders can manage their own care or have help from others, and although she acknowledged that it was wrong, she said that that had played a part in her mind.
Friday 11th January 2013 the Council were aware of all but three of the service users whose care was provided by the Company and set about making alternative care arrangements for them. Following the raid the details of the remaining three service users were made available to the Council. All three of those remaining service users, who included Mrs Foster, were funding their care privately. By 13.00 hours on the 15th January 2013 Mrs Foster’s details, including the nature and the frequency of the care provided, namely four times per day, were known to the Banstead and Reigate Locality team, being the team within the Council with responsibility for organising an alternative care package on her behalf. In the event, nothing was done to arrange alternative care. Consequently, Mrs Foster was left on her own, incapable of looking after herself and with no care, for a period of nine days until she was discovered by a District Nurse. She was admitted to Epsom General Hospital very seriously ill and received treatment for a number of different problems including dehydration. Despite that treatment, she died on the 4th February 2013, whilst still at the hospital. The immobility and the dehydration from that nine day period was found to have made a material contribution to the cause of her death. No proper explanation was given by the Council for the failure to arrange suitable alternative care. The Banstead and Reigate Locality Team were under great pressure of work at the time and the Senior Operation Lead from that team, to whom the task of arranging suitable alternative care had been delegated, said that she had been influenced by the fact that Mrs Foster was a ‘self‐funder’. She went on to say that there is a bit of an assumption that self funders can manage their own care or have help from others, and although she acknowledged that it was wrong, she said that that had played a part in her mind.
Copies Sent To
3. Surrey County Council
6. Signed
Richard Travers
DATED this 10th day of September 2014
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.