Dear SirIMadam Re: HAROLD DE MELLO The Coroner's Report into Mr De Mello's death was received on 17 July 2014. This report raised serious concerns in what the Coroner considered to be failings on the part of London Borough of Tower Hamlets Social Services The Coroner concluded that Mr De Mello had number of health and mobility issues and that an assessment by Tower Hamlets Social Care failed to identify that he was living in unhygienic and unsafe conditions and action should have been taken. Although the cause of his death was bronchopneumonia, the Coroner ruled that it was caused by a lack of hygiene and therefore neglect was deemed a contributing factor. In accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013, the London Borough of Tower Hamlets was required to respond to the Coroner's concerns detailing timetable for action to be taken in respect of preventing future deaths_ A Case Review meeting was convened to analyse the Council's actions on Mr De Mello's case and consider what immediate practice issues should be addressed_ This was followed by a meeting with the Independent Chair of Tower Hamlets' Local Safeguarding Adults Board to review the case and consider the need for serious case review or internal management review. The Chair took the view that an internal management review would be most appropriate _ and this was urgently commissioned, The internal management review of Mr De Mello's case sought to; EQUALITY FRAMEWORK FOR LOCAL INVESTORS GOVERNMENT Lexcel EXCELLENT 0/5a8149 IN PEOPLE Soclcty Acctaditeu

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a) Undertake a review and analysis of social work practice and management decisions taken in context of concerns raised by the Coroner and compliance with best practice_ b) Submit recommendations arising from the internal management review: The comprehensive internal review was completed on 3 October 2014 and this has identified a number of areas where changes to practice or procedure have been implemented since Mr De Mello's death or are currently being progressed, and where further improvements can be made to service provision to enhance the protection and wellbeing of vulnerable adults. The action plan arising from the review is enclosed in compliance with the requirements of Regulation 29. Compliance with the deadlines set in the action plan will be formally monitored through the Council's RAG monitoring system. If the Coroner has any further queries or concerns, please do not hesitate to contact me Principal Lawyer; Social Care Team Eor_ Service Head Leqal Services DECEIEn 2014 CORONER'S OCt 1 5 COURT POPLAR '

Action Plan arising from Internal Management Review (HD) Targeted Action Area Recommendation Details Responsible Target Officer(s) Date and RAG status Immediate Practice Disseminate internal management review and action plan to management October Improvements team: Long Term Team 2014 Phase 1: share with Service Managers Service Manager Phase 2: share with the respective team managers from both frontline teams together, taking a whole system approach Phase 3: the respective team managers present the action plan to their teams for implementation Lessons learned from this case to be shared with the staff in the First Team Manager, First November Response Team and across the Department for discussion, reflection and Response Team_ 2014 reinforcement of national best practice guidance: Service Users are given opportunity to invite other people to their assessment: Evidenced cross checking of the role and needs of informal carers within the service users supportlwellbeing plan (formal or informal): Long Term Team Standard procedure to supply, with service user consent, feedback Service Manager to referrers on outcome of social care interventions_ Robust management scrutiny of assessmentlinterventions undertaken, checking for discrepancies between reports. Management instruction and decision making processljustification clearly evidenced in all decisions and case closures. Clear recording_of decision making_rational on the assessment of

Action Plan arising from Internal Management Review (HD) risk and application of FACS eligibility criteria evidenced in all assessments by all levels of staff. Quality and proportionate signposting and wellbeing planning for Service users who do not meet eligibility thresholds_ Implementation of a new practice protocol within the First Response Team Adult Social Care Completed and across the Department of ensuring copies of case closure letters are Dept sent to the referrer with the service user's permission, thereby providing opportunity for the referrer to raise any concerns with the outcome Introduction of a new mandatory Carers' Views section in the electronic Adult Social Care Completed record (Frameworkl) which records informal carer involvement thereby Dept: ensuring all supportive networks are considered as part of the assessment process. This reduce risk of carers not being involved in the assessment process in the future. Quality Assurance Appointment of a Principal Social Worker within the Adult Social Care Principal Social Completed Programme department to embed research and evidenced practice within Adult Social Worker Care teams which supports an organisational culture of reflection, learning and skills development: Strengthen/Modify the existing quality assurance framework within the Principal Social December Department to ensure learnings identified this case review are Worker_ 2014 embedded into general practice Learning and Development Lead Strategy & Performance Team Development ofa Risk Development of a risk analysis tool designed to enable positive risk taking Principal Social December 2 will from

Action Plan arising from Internal Management Review (HD) Analysis Framework and planning derived the Signs of Wellbeing and Safety framework Worker 2014 Such a framework would recognise likely areas of disagreement between people, their family, carers and practitioners and guidance on how to negotiate the service user's desired outcomes_ Introduction of an eco-mapping tool which facilitates identification of a December person's support network thereby ensuring quality, informed decision Term Team 2014 making and risks are appropriately identified and managed. The tool will Service Manager support practitioners to consider: Who and what agencies are involved? What is helping? What is hindering? Where are the gaps in support? A programme of targeted Critical/Cumulative Analysis training with staff Learning and December members has been scheduled for December 2014. Development Lead 2014 Care Act With the implementation of the Care Act in April 2015 the London Borough April 2015 Implementation April of Tower Hamlets are in the formal process of developing: Programme Manager, 2015 Development of
1) A new assessment and eligibility framework informed by best Head new practice of Service framework. practice guidance_
2) Clarity of roles and responsibilities for various levels of practitioners across the Adult Social Care department. Principal Social
3) A comprehensive training programme for staff resulting in a highly Worker and Service & skilled and confident workforce. Learning and
4) Multi Agency practice guidance on the intervention and support to Development Leads people who may be at risk of self-neglecting and poor environmental Care Act Workstream hygiene.
2.1: Assessment; Eligibility & Support Planning from Long