Dear Mr Osbourne Re: Derrick Arthur PLATER (deceased) Response to Regulation 28 report concerning the death of Mr D A Plater Thank you for your letter dated 24 March 2014 requesting a response to a Regulation 28 Report: Please accept this letter as that response pursuant to Regulation 29 of the Coroners (Investigations) Regulations 2013. In your report you were concerned that there was a total reliance upon assurances given by the care home, Goodwins Hall; that it could meet Mr Plater's needs. At the Inquest into Mr Plater's death_ Cambridgeshire County Council's witness, tried to explain that under the terms of the care home's registration with the Quality Commission the Registered Manager; in each home, is responsible for determining whether the assessed needs can be met in their care home The decision to accept the placement by the care home is based on the health and social care assessments provided to the home_ That decision is usually supported by staff from the home visiting the person in hospital to complete their own assessment before making a decision to accept the placement: lexplained that the social worker completed a comprehensive assessment of Mr Plater's social care needs to enable the home to reach their decision: Hospital staff were responsible for completing the assessment of Mr Plater's on- going health needs The social worker sought reassurance from the multi- disciplinary team in the hospital that they were confident that the home could meet these needs. Discussions took place between ward staff and staff from the home and the senior nurse from the hospital team confirmed to the social worker that she O15A8L69 Avel Rooe)(aper Chief Executive: Mark Lloyci WwW cambridgeshire gov.uk Care About 0 1

felt that the needs arising from Mr Plater's laryngectomy and stoma could be met at Goodwins Hall: said that the social worker was aware that staff from the home had carried out their own assessment of Mr Plater's needs by visiting him in hospital prior to accepting his placement: As a consequence of repeated questioning on the discharge planning and placement process and the stress of attending the Inquest, lindicated that if similar circumstances arose today it is likely that a visit by a social worker would be undertaken before the placement was made On reflection Trecognises that this response was not correct. Isincerely regrets that she was unable to clearly explain to you the Registered Manager's responsibilities at the care home and assure you that the social worker had fullv carried out their duties to enable the home to make an informed decision_ also apologises for indicating that a visit would be undertaken in future_ In Mr Platter's case where there were complex health and social care needs, a visit to the home by a social worker would not; in my opinion; have provided any added assurance because social workers are not professionally competent to make judgements on whether Mr Plater's health needs were likely to be met at Goodwins Hall: Therefore , believe that it is unlikely that a pre-placement visit in these circumstances would help to prevent future deaths in similar circumstances For the reasons presented above a pre-placement visit by a social worker is not and will not be part of the assessment and placement process and there are no plans to introduce this step am not aware of any Local Authority that routinely undertakes a pre- placement visit in these circumstances. However, please be assured that if we had received information, from any source, that Mr Plater's needs were not being met this would have been investigated immediately and steps taken to ensure that his needs were met at Goodwins Hall or arrangements made to transfer him to another home_