SERIOUSCASEREVIEWINTOTHE DEATHOFJESSEMOORESON NOV3RD2005

REVIEWCARRIEDOUTBYHILARYBROWN,PROFESSOROFSOCIALCARE, CANTERBURYCHRISTCHURCHUNIVERSITYONBEHALFOFBARNETAND ENFIELDSAFEGUARDINGADULTSBOARDS.

P REFACE
Whensomeoneusinghealthandsocialcareservicesdiesapreventabledeath,itis rightthatasearchlightbedirectedontheirserviceanditsarrangements,including factorsthathaveaffectedthesituationatoneremove. ThedeathofJesseMooresattheageof26wasatragicaccidentbuttherehadbeen sufficientsignalsabouthishealth,andabouthisservice,tosuggestthatitwasan accidentthatcouldhavebeenprevented.Theeventsofthatdayandofthe precedingweekswerepresentedandtestedincourt:theseriouscasereview summarisedbutdidnotgobackoverthatprocess.Instead,asapanel,andas participatingagencies,weaskedwhatwentwrong,andwhathasbeendoneto remedythosefaultlines,sothatwecanusehindsightasareferencepointagainst

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whichtointerrogatecurrentservices,askingCouldthishappennow?andWhat elseneedstobedone?. JesseMoores,wasayoungmanof26,withlearningdisabilities,autismand TourettesSydrome,livingatTheChine,aresidentialhomerunbyRobiniaCare.He wasamuchlovedsonandbrother.Healsohadchallengingbehaviour,specificallya compulsiontoputobjects,whetheredibleorinedibleinhismouth.Hediedon3rd Nov2005,havingchokedonahamsandwichthathehadgrabbedfrom,orbeen givenby,anotherresident.Itislikelythathetookthesandwichtohisbedroom wherehediedunobserved.Whenhewasfoundfirstaidorresuscitationwasnot administeredandtherewasadelayincallinganambulance.Itisunclearwhetherby thetimehewasfoundanythingcouldhavebeendonetosavehislife. Thisresidentialunitexistedatthehubofamuchwidersystemofcommissioning, funding,assessment,careandsupport.Hissocialcarewastheresponsibilityofthe LondonBoroughofBarnet.Theyweresupposedtohaveadetailedcontractwith RobiniaCarespecifyingthequalityofcarethattheyexpectedandthewaythey wantedthisservicetoaddressJessesparticularneedsandchallengingbehaviour.In facttherewasnorobustorenforceablecontractinplaceandwhilethismaynot havecontributeddirectlytoJessesdeath,itsetthetonethatledtoan unaccountableservice,operatinginacavalierway.Thislackofclarityextendedto thetwodaycentreswhichheattendedasthesewerenottiedintomechanisms thatwouldhaveallowedthemtoformallyshareconcernsorcontributetoshared riskmanagementacrossalltheservicesthatJesseused. Contractinghastwoseparateelements:firstlytheservicelevelcontractthat specifiesthestandardsandarrangementsthatstandbetweenthelocalauthority andtheprovideragency,andsecondlyanindividualcareplanspecifyingthe particularneedsofthepersonwhoseplacementisbeingsetup.Annualreviews werecarriedoutalthoughJessesdesignatedsocialworkerleftin2004andhis familywerenotkeptabreastofthis.MrMooreshasexpressedconcerntolearnthat thiskindofcasewouldnowbeheldbythedutyteamashisviewwasthatthe designatedworkerhadprovidedvaluablecoordinationduringthetimeshewas Jessessocialworkeroverandaboveherattendanceatthesereviews.Atthese reviewstheriskofchokingwasnotspecificallyidentifiedormadethefocusof detailedplans. TheLondonBoroughofBarnetwhowerepayingforJessescareshouldalsohave organisedpropermonitoringofthisservicesincemisgivingshadbeenexpressed throughrelatives/familymeetingsatwhichconcernshadbeenraisedaboutthe managementof,andstaffingarrangementsat,theChine(RobiniaCare) JesseshealthcarewastheresponsibilityofEnfieldPCT,coordinatedbyhisGPas wouldbethecaseforanyothercitizen.Inadditiontothishehadrecoursetothe CommunityLearningDisabilityTeamwithitsspecialisthealthcareprofessionals,he wasseenbyapsychiatristinrelationtohishyperactivityandbyaspeechand languagetherapistinrelationtohiscommunicationneeds.Theservicedidnot implementprogrammesthatweresuggestedtohelphimwithhiscommunication. Noreferralhadbeenmadewithregardtohisputtingobjectsinhismouthorthe riskofchoking.ThiskindofcasewouldnowbediscussedattheIntegratedLD Page2

ServicesComplexCasePanelandaplanofactiondecided.SadlyJessescase occurredpriortointegrationofLDservicesinEnfieldwhensuchaforumdidnot exist.

T HEEVENTSLEADINGUPTO J ESSE SDEATH

ANESCALATINGRISKOFCHOKING TheCourtTranscriptreferstothefactthatJessehadchokedfourtimesin theweeksleadinguptohisdeathbuttheseincidentsdidnotleadto concertedactionortoincreasedsupervision,norweretheysharedwithMr Mooresastheyshouldhavebeen.Moreoverasafeguardingalerthadbeen raisedinrelationtoanincidentwhereamemberofthepublichad witnessedtwomembersofRobiniastaffusingunnecessarilyaggressive forcetoremovesomethingfromJessesmouthinthepreviousyear.Two meetingswereheldandanactionplanagreedwithTheChinetoaddress theserisksbuteitherthiswasnotimplementedand/ortheplacementwas notproperlymonitoredinthelightofthis. Giventhesefourpreviouschokingincidents,andtheprevioussafeguarding intervention,Jessesdeathwasanaccidentthatstaffshouldhavebeen preparedtopreventandonethattheyshouldhavebeencompetentto respondto.Itisnotthecasethattheriskswerenotknown,butitisthe casethattheyweredownplayedandthatthesharingofinformationwas illcoordinatedandunfocussed.Inguidanceonthesematters,chokingwas dealtwithasanissueformealtimes,separatelyfromJessestendencyto pickupthingsandputtheminhismouthorhishabitofgrabbingfoodand eatingitawayfromthetable.

T HEDAYHED I ED
STAFFINGPROBLEMS AtthehousewhereJesselivedthereshouldhavebeenthreestaffonduty onthemorningshiftbutonthedayJessediedtwounqualifiedand inexperiencedcareworkershadbeenhiredonacasualbasisfroman agencycalledSynergybecausetherewereinsufficientpermanent membersofstaffatthehomeoravailabletobeonduty,onewasworking underanassumednameanditwassuggestedthattheHomesManager mighthaveknownthis.Theregisteredhomemanagerwasworkingouthis noticeatthetimestatingthathisreasonsforleavingwerethatthe managementofRobiniaCarehadmovedexperiencedstafftoanother homethattheyhadrecentlyopenedintheneighbourhoodwithoutbeing replaced.Hesaidthatdespitenumerousrequestsfromhimtothe companysseniormanagement,theywouldnotprovidesufficientstaff.He hadnottakenhisconcernstotheotherauthoritiesconcernedwith commissioningorregulatingtheservice.

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Ithasnotbeenpossibletorecovertheoriginalrotasbut,theinvestigators whohadseenthem,andthephotocopiesdemonstratethattherewere insufficientpermanentstaffandthattherotawasinastateoffluxwithlast minutesubstitutionsacommonplacefeature. Theonlyexperiencedmemberofstaffondutythatmorningwasthe DeputyManager.Itemergedthatshehadasecondjobinaschooland RobiniaCaredeemedthisabreachofhercontractasshehadnotdeclared thispostonherapplicationform.Whensheleftthatmorningshesaidshe wasgoingshoppingandtothePharmacyforTheChinebutshewas actuallygoingtoherotherplaceofwork.Althoughshewasnotresponsible forthelackofstaff,shewasondutyandformallyresponsibleduringthat morningshift,andbyleavingsheabdicatedherresponsibilitytothethree vulnerablepeopleinhercare.Heraccountoftheeventsofthatmorning, andofherownmovementsandactions,keptchangingrightupto,and during,thecourtcase. HOWJESSECHOKED Jessewasnotseendownstairsafter8.30amanditisnotclearwhenhe grabbedthesandwichfromanotherresidentspackedlunch.Therewere conflictingaccountsgivenastowhetherhechokeddownstairsandwas carrieduptohisroom,orifhetookthesandwichtohisroomwherehe chokedunobserved,thelatterseemsmoreconsistentwitheveryones actionsafterthatpoint.OneoftheagencyworkersfoundJesseseemingly asleeponhisbedatabout915am. THEIMMEDIATERESPONSE Ondiscoveringhimlyinglifelessonhisbed,shecalledhercolleagueup fromthegroundfloor.Heassumedthathiscolleaguehadfirstaidskillsbut thefactthatshewasworkingunderanassumedname,withfalse certificates,meantthatthiswasnotthecase.Neitherofthesestaffwere briefedabout,orpreparedtorespondto,Jessesriskofchoking.Nordid theyhaveinformationaboutwhattodoinanemergencyotherthantoring theDeputyManagerwhohadleftthebuilding.Wecaninferthattheydid notfeelauthorisedtoring999directlyandthepersonwhofoundJesse wasactuallyinstructednottodoanythinguntiltheDeputyManage returnedtothehome. Therefollowedanavoidabledelaybeforetheambulancewascalled.When theparamedicsdideventuallyarrivetheyattemptedresuscitationbutit wastoolate.InsteadoftryingtoclearJessesairwaysorplacehimina recoverypositionitispossiblethattheworker,believinghimtohave alreadydied,laidhimouthopingtoexpressrespectandkindliness howevermisguided. Thefactisthatnocoherentaccounthasbeengivenandthisislargelythe responsibilityoftheDeputyManager,perhapswithcollusionfromother staff.Itisthereforeimpossibletoestablishwhetherthedelayin summoningemergencyservicescontributeddirectlytoJessesdeath,orif Page4

thestaffwereactinginthebeliefthatitwasalreadytoolatetosavehim. ThisrefusaltoprovideaconsistentaccounthasaddedconsiderablytoMr Mooresdistressandanger. Jessewaspronounceddeadat10.47amatChaseFarmHospital.Mr Mooresarrivedatthehospitalatabout11.45am,assoonashecouldgiven thelengthofhisjourneyandhewastoldthenthathissonhaddied.The SocialWorkTeamLeaderatBarnetSocialServiceswastoldbytelephone laterthatafternoon.

S ECTION 2 T HEROOTCAUSEANALYSIS
Ascanbeseenfromthisreportandfromthepanelsdeliberations,thereis no,one,simpleanswertothequestionofcausation.Manyfactors convergedtoallowJessetochokethatmorningandtoblockanychanceof theimmediatehelpthatwouldhavebeennecessarytoresuscitatehim. Thissectionhastriedtoenumeratethoseactsandomissionsthatcame togethertomakethiseventualitymorelikelybeforehedied,duringthe crisisandthenthathinderedunderstandingafterwards. BEFOREJESSESDEATH Jessescompulsiontoputthingsinhismouthhadnotledtoa formaldiagnosisorspecificbehaviouralprogrammeandnorwere hisdifficultieswitheatingandchokingformalisedbyhealth professionals BarnetSocialServiceshadnotdrawnupapropercontractwith RobiniaCareandnorwasthereanymeaningfulcontract monitoringorcomplianceactivity ThiscontractdidnotspecifytheparticularneedsthatJesse Moorespresentedwith RobiniaCarehadsubcontractedpartoftheservice(daycare) unofficially ThecontractbetweenBarnetandRobiniadidnotprecludesuch subcontractingsothatJessewasattendingthreeserviceswithout propercoordinationandcommunicationbetweenthem Insufficientnoticewaspaidtotheriskassessmentsandprevious safeguardinginterventionthathadbeencarriedoutwithregard toJesseshabitofputtingobjectsinhismouthandhistendencyto takefoodfromotherpeoplebothofwhichledtoariskofchoking notonlyatmealtimesbutatalltimes TheserisksthathadbeensetoutinAugust2004werenot incorporatedintohiscareplansotheywerelostasstaffleftand werereplaced. TherewerefournearmissesinthemonthsleadinguptoJesses death:RobiniaCaredidnotreportoractuponthem

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Familymembersexpressedconcernsaboutinsufficientstaffat thehomeduringameetingheldinSeptember2005butthiswas notformulatedintoaformalcomplaintorfollowedup TheagencyworkerwhofoundJessesaidinhertestimonythatshe didnotknowaboutJesseschokingproblemseventhoughshehad beenworkingatthehouseforseveralmonths,shealsosaidshe didnotknowhehadhisfoodliquidized. Allstaffshouldhavebeeninformedaboutthepreviousincidents ofchokingandinstructedaboutwhattodoinanemergency ThisagencyworkersaidshehadtoldtheHomeManagerthatshe wasworkingunderfalsepapers:itwashisresponsibilitytoassure thatshehadproperclearancesandfirstaidqualifications. TheHomeManagerhadremonstratedwithRobiniabecausethey hadmovedstafftoadifferenthomewithoutwaitingforTheChine torecruitreplacements:hegaveinhisnoticebutdidnotblowthe whistleoutsideofhislinemanagement RobiniaCarehadnotheededthesewarningsaboutinsufficient staffing DMdidnotinformRobiniaCarethatshehadasecondjob BarnetSocialServiceshadnotreplacedJessesallocatedsocial workerwhensheleft Jessewasheldbythedutyteamandnotallocatedtoaspecific socialworker:evencomplexclientsareheldonreviewinthisway HealthprofessionalsespeciallytheSaLThadexperiencedthis homeasobstructiveandunabletofollowthroughonexpert adviceandtreatmentprogrammesbuthadnotbroughtthistothe noticeofotherresponsibleagencies Therotawasunclear,theDeputyManagerhadbeenaskedto comeinatthelastmomentandoutsideherusualshiftpattern Therewerenoclearinstructionsatthehomeabouthowto respondtoamedicalemergencyorwhattodoifsomeonechoked (eventhoughthiswasarecognizedriskforJesse) Jessesfatherhadnotbeeninformedaboutthefournearmisses ortheescalatingrisk Synergyhadnotprovidedproperfirstaidtrainingtoatleastone oftheagencyworkers Synergysrecruitmentpracticeshadnotbeensufficientlyrobustto ensurethattheirworkersidentificationdocumentswerevalid, thismayhaveledtotheirplacingherinignoranceofherlackof experienceortraining InsufficientnoticepaidwasbytheChinetoreportsofJesse chokingfromthetwodayservicesthatheattended:therewasno systematichandoverorreportingbackfromthem Hooveringanddomestictasksasopposedtoengagementwith residentswasprioritisedatthishome Page6

DURINGTHECRISIS Therewasnoproperhandoverinstructingthetwoagencycare workersabouttherisktoJesseandhowtosupervisehim Anexperiencedmemberofstaffwasonlongtermsickleave puttingpressureontheManagerandDeputyManagertocometo workwhentheyshouldhavebeentakingtimeoff TheDeputyManagerleftthehomeinchargeoftwoinexperienced agencyworkers:thehomewasregisteredonthebasisofthere beingthreeworkersonthemorningshift OneoftheagencyworkershadonlyworkedatTheChineforafew dayspriortothisemergencywherehewasprimarilyadriverbut hedidhavefirstaidtrainingandknewwhatshouldandcould havebeendone:ifaformalhandoverhadtakenplaceitcould havebeenmademoreexplicitwhowasonchargeduringtheshift andwhowastotakechargeinanykindofmedicalemergency. Carestaffwerenot,ordidnotfeel,authorizedtocall999directly toensurethatJessereceivedimmediateresuscitationand emergencytreatment TheDeputyManagertoldtheworkerstowaituntilshereturned whensheshouldhavetoldthemtocallanambulance immediately:itispossiblethatshebelievedJessehadalreadydied Shethencalledtheambulanceonamobileandnotthelandline fromthehousewhichwouldhavehelpedtheLondonAmbulance Servicetohavelocatedthehome Nofirstaidwasattempted Jessehadnotbeenputintherecoveryposition Staffgaveaconfusedaccountofeventstotheparamedics MrMooreswasnotcalleduntilalmost45minutesafterJessehad beenfoundunconscious BarnetSocialServiceswerenotcalleduntillaterthatafternoon AFTERWARDS BarnetdidnotimmediatelycallEnfieldandaskthemtoinstigatea SafeguardingAdultsInvestigation AninternalreviewwascarriedoutbytheAreaManagerfor RobiniawithouttheoversightofEnfieldSafeguardingTeam StaffatTheChinegaveconflictingandcontradictoryaccountsof theeventsofthatmorning TherewasconfusionaboutwhowastoliaisewithMrMoores duringthedaysandweeksafterJessediedandhowfartheycould goinhelpinghimtoaccesstheinformationheneededtomake senseofthesituation:heeventuallyreceivedhelpfromboth socialservicedepartments(BarnetandEnfield)butthis,initself, presentedsomeconflictsofinterest

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WhenchallengedbyMrMoores,BarnetSocialServices prevaricatedaboutanewcontractbeinginplace,thiswasnotthe caseuntilNovember2008 BarnetSocialServicessoughttoevadebeingidentifiedwiththe casebywithdrawingfromajointpressstatementwhichleftMr Mooresfeelingunsupportedandangry RobiniaCarefailedtoreferthestaffconcernedtothePOVA 1 list untilthiswasinsisteduponbyCSCI(nowCQC) Thesafeguardinginvestigationwashaltedwhilepoliceconsidered theoptions,thisdelayedmattersunduly NoSeriousUntowardIncidentreportwascompletedregarding thehealthcareaspectsofJessespreventabledeath TheLondonBoroughofBarnetdidnotseeklegalrecompense fromRobiniaCareonbehalfofMrMoores Inthissadstorymanythingswentwrong.Thereisnoonechainofevents tofollowbutatangledwebinwhichseparatestrandscanbeseentying Jesseintothishighrisksituation.Moreover,hiscareraisedseriousdoubts aboutthewayprofessionalshadworkedtogetherinthecommissioningof hisservice,incareplanningandriskassessment,andinthedismissiveway inwhichspecialisthealthcareandexpertadvicewasdiscardedbyJesses service.Theserviceitselfwasoverreliantonagencystaffandrecruiting fromaverydisadvantagedworkforce.Theconsequencewasthatthe LondonBoroughofBarnetfailedtoprovidearesidentialplacementthat couldmeetJessesneedsinasafeanddignifiedenvironmentandCSCI failedtomonitorthehomecloselyenoughtoensurethattheywere compliantwithminimumstandardsinrespectofstaffingandsafepractice.

S ECTION 3 A CTIONSTAKENTOHOLDINDIVIDUALS ANDAGENCIESTOACCOUNT

A C T I ON S T A K E N A G A IN S T T H E IN D I V I D U A L S H E L D RESPONSIBLE
AprosecutionformanslaughterwasconsideredbythepolicebuttheCPS werenotpersuadedthattheycouldpresentanadequatecasetosupport thischarge.SubsequentlytheManagerandDeputyManagerwere prosecutedunderHealthandSafetylegislation.Theywerechargedwith failingtocomplywithSections7and33oftheHealthandSafetyatWork Act1974.Dueprocesswasappliedtotheiraccountswithafindingof culpabilityinrelationtotheformerDeputyManagerandofnotguiltyin thecaseoftheManager.Thisisimportantbutitisalsothecasethatduring theinvestigationitbecameclearthatthisservicehadbecomeunsafefor JesseMooresandthathisriskofchokingwasnotbeingproperlymonitored ThiswastheprecursortotheVettingandBarringSchemecurrentlyoperatedby theIndependentSafeguardingAuthority. Page8

ormanaged.Theseomissionswerenotthesoleresponsibilityofthetwo staffchargedoroftheDeputyManagerwhowasconvicted.

A C T I ON S T A K E N A G A IN S T T H E S E R V I C E S R E SP O N S I B L E F O R JESSEATTHETIMEOFHISDEATH
RobiniaCareasanorganizationalsopleadedguiltytochargesputtothem underHealthandSafetylegislationsothattheydidnotgothroughthe courtprocess.Theywerefinedatotalof250,000.MrMooreshadurged theLBofBarnettotakeactionagainstRobiniaonthegroundsofbreachof contractonlytofindthatthecontractwasnotadequatelydrawnupand thereforecouldnotbeusedtoholdthemtoaccount. SubsequentlyMrMooressoughtanswersfromBarnetSocialServices, throughalengthyanddistressingcorrespondenceoverthreeyears,about thewayinwhichtheyhadcommissionedandcontractedJessescarefrom thiscompanyandinsistedonbeingshownnew,revisedcontracts.Barnet explainedthedelayinimplementinganewcontractasaconsequenceof ongoingdiscussionsabouttheimplementationofapanLondonuniversal contractforalllearningdisabilityservices.Whilelaudable,thisshouldnot havebeenallowedtoblockthedevelopmentofanimprovedcontractfor interimuse.Itisunthinkablethatlargeamountsofpublicmoneyshouldbe committedwithoutabindingcontractualarrangement.ABarnetspecific servicespecificationwasimplementedby2008whichstrengthenedthe processesofaccountabilitybetweentheauthorityandprovideragencies. TheNHShasnotconductedanSUIorotherreviewoftheirinvolvementin, orresponsibilityinrelationto,Jessesdeath.Itisunclearwhetherthey reportedhisdeathtotheNPSAasapreventabledeathinlinewiththeir governancerequirements.ItseemshoweverthatJessesheightenedrisk ofchoking,soclearlysignalledbythesepreviousincidents,hadnotledto anycoordinatedassessmentorriskplanningasiscurrentlyrecommended bytheNPSA.Hishealthcarewasnotthereforebeingadequately coordinatedalthoughhewasbeingregularlyreviewedbyhisGP. TheSafeguardingLeadinEnfield,workedcloselywithCQC(CSCIasitwas then)overChristmasof2005toensurethatsufficientimmediatesafety measureswereputinplacebyRobiniaCareoverthenextfewmonthsto assurethesafetyofotherresidentsbuttheproviderfailedtoreachan acceptablestandardandcommissionersfoundotherplacements,sothat thehomebecamefinanciallynotviableandclosedinDecember2006.The Panelareoftheviewthatinsufficientenforcementactionwastaken againstthishomeandthatearlierproblemshadnotbeenrespondedto withatoughenoughapproach.Thisisundoubtedlyacriticalareafor debateasweenteraperiodoflighterregulationandeconomicausterity.

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S ECTION 4 R ECOMMENDATIONSAND C ONCLUDING REMARKS

Thefollowingrecommendationsaretobeusedasthebasisforactionplans foreachagencythathasbeenpartytothisreview.Thesewillberatifiedby thePanelandmonitoredbothinhouseandbytherespectiveSafeguarding AdultsBoards.

Action Amendreportableincidentsstipulation

Agenciesaffected BarnetCommissioningand ContractingTeam PanLondonSafeguarding EditorialBoard

Althoughparagraph2.7ofthePan London 2 multiagencypolicyand procedurestoprotectadultsfrom abusestatesthatapoliceinvestigation shouldtakeprimacywhenthisis reviewedin2014thissectionshouldbe expandedtostatethatsuchapolice investigationwithaviewtoprosecution shouldnotunreasonablyhaltother agenciesgovernanceandmanagerial actionssothatthesecantakeplacein parallel,withsuitableprovisossoasnot tocompromiseprosecutionor evidencegathering BothBarnetandEnfieldAdultSocial Careshoulddevelopinformationand intelligencegatheringsystemsthat respondtoalertsaboutindividualsat riskandtoconcernsaboutfailing servicesandthesetwosystemsmust speaktoeachother Chokinganddysphagiashouldbedealt withinlinewithNPSAguidelinesand clientswithPICAshouldbesubjectto multidisciplinaryassessmentandrisk managementuntilsuchtimeasa specificprotocolisdevelopedaround thiscondition. Revisitthecontinuingcareguidance andmakeitmorespecifictopeople

Timeframe Immediately Within6months 2014

LondonBoroughsofEnfield 1218months andBarnettobesharedwith PanLondonEditorialBoard

EnfieldandBarnetCLDTs

6months

ChairtowritetoDHandNHS Enfield

2 Protectingadultsatrisk:Londonmultiagencypolicyandprocedures tosafeguardadultsfromabuseProducedbytheSocialCareInstituteforExcellence withthePanLondonAdultSafeguardingEditorialBoard2011 Page10

withautismandchallengingbehaviours FunctionalAssessmentbyclinical psychologistsshouldbethenormfor individualswhohaveacompulsionto putobjectsintheirmouthanddetailed riskmanagementplansshouldbe drawnuptogovernthewaytheir everydaylivingsituationshouldbe managedtoreduceandifnecessary respondtoincidents Negotiationsshouldbeginacross LondonthroughthePanLondon SafeguardingBoard,tosetupasystem foralertinghostauthoritiestooutof boroughplacementsbeingmadeon behalfofindividualswhorequire immediateand/orcomplexhealthcare arrangementstobeinplace:this shouldincludeanypreviousincidents ofchokingorchallengingbehaviour thatrequiresassessmentbyaclinical psychologist. Contractsshouldspecifythata residentialserviceregisteraperson withalearningdisabilitywithaGP withinfourteendaysoftheirtakingup residenceinanewplacement. Guidelinesonwhistleblowingshould becirculatedtoallRegisteredHome ManagersinbothBoroughsand significantproblemsinrecruiting sufficientstaffshouldbeincludedas oneexampleofmattersthatshould leadtoreportingofconcernsoutside immediatelinemanagement AtalocallevelCLDTtoensure assessmentprocessappropriately highlightstheneedsofpeoplewith autismandchallengingbehaviours. Progressincommissioningautism specificservicesshouldbesharedwith bothBarnetandEnfieldsSafeguarding AdultsBoardsandnotedintheirannual reports Numbersandtrendsincommissioning outofboroughplacementshouldbe sharedwiththeSafeguardingAdults Boardandmonitoredintermsofthe implicationsforsafeguardingofboth outplacedbutalsoincoming placements

HBtoliaisewithBritish PsychologicalSocietyand withNICE/DH

12months

LBBarnettoliaisewithPan LondonCommissioning groups PCTtodesign/modifythe HealthAlertFormforthis purpose

12months

LBBarnettoliaisewithPan LondonCommissioning groups

12months

L.BBarnetandEnfield

3months

EnfieldandBarnetCTLD

6months

LBofBarnetandEnfield

12months

LBBarnetandEnfieldshould addressthisonalocallevel butlinkinwiththepan LondonSafeguardingBoard andADASSrelatingtotheir guidanceonordinary residence

12months

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Itshouldbemadeclearinalljob descriptionsandcontractsthatthejob ofcarestaffistoengagewith residents/serviceusersandnotonlyto actasdomesticstaff.Thecontract shouldspecifythattheyexpectcare stafftoworkwithresidentsincarrying outeverydaycooking,cleaningand maintenanceandthattheyshould prioritiseengagingwithserviceusers overcleaningchores. Anominatedfirstaidershouldbe designatedatthestartofeachshiftifat allpossiblebutALLstaffshouldhave basicfirstaidtraining.Homescannot affordtohaveallstafftrainedonthe certificatedcoursessoshiftsystems mayprecludethisrecommendation actuallyhappeningbetterthatall staffhavebasictrainingandalsoknow abouttheuseof999emergency services. Allhomesmustdisplayallemergency contactdetailsonpublicnoticeboards. Staffshouldhavebasictraininginand anunderstandingofwhentocall emergencyserviceandknowthatthey donotneedtowaitfortheirmanagers approvalbeforecalling999whenthe situationisurgentand/orpotentially dangerous.Amaximtoconveythisisif indoubt,callthemout. Clarifyarrangementsfortakingcontrol ofserviceleveldocumentationaftera deathorseriousuntowardincident Setinplaceaformalfamilyliaison schemetosupportabereavedperson throughoutasafeguarding investigationanditsaftermathincases thathavegivenrisetoparticularstress anddistress. GuidanceontheconductofSUI reportingshouldspecifythewhen incidentsinvolvingpeoplewithlearning disabilities,andcommunityservicesfall withinthisprotocol Apolicyshouldbedrawnuptosetout howhealthcareprofessionalsshould respondtomissedappointments,orto aservicethatfailstoactonexpert

LBBarnetCommissioning

6months

ProviderGroupstobe informedthroughsubgroup ofSAB

4months

SABproviderliaisongroups inEnfieldandBarnet

LBBarnettoliaisewithPan LondonSafeguardingpolicy group LBBarnetandEnfield

6months

6months

NHSEnfield

3months

LBEnfieldCLDTtobeshared 12months withBarnetCLDT

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advicegivenortoimplement recommendedtreatmentprogrammes Linkinwithnationalinitiativesto advocatefor,andsupport,thesocial careworkforce,includingOxfams recentcampaigntoimprovethe workingconditionsofmigrantworkers inthesocialcaresector LinkinwithADASS,DH,theLondon IndependentChairsnetwork,andother nationalnetworkstofindwaysof ensuringthatrecommendationsfrom thisandotherseriouscasereviewscan beimplementedonanationalbasis

HBtoreportbacktoBarnet SafeguardingAdultsBoard

12months

LondonBoroughsofBarnet 3years andEnfield,CQC,HBasChair ofthispanel

C ONCLUSION
AFTERWORD Thiswasanunsafeservicethatdidnothavetheexpertiseorresourcesto assureJesseMooresbasicsafety.AtthetimeofJessesdeaththerewere seriousdeficienciesinthecommissioningandcontractingarrangements putinplacebytheLondonBoroughofBarnetandthesewereexacerbated bydiscontinuityintheprovisionofsocialworksupport,afailuretoreport concernsandincidentsonthepartofRobiniaCare,inadequaterisk managementandmissedreviews.Therewasalsoafailureonthepartof EnfieldPCTtoprovideadequatespecialisthealthcareadviceandseeit actedupon.Jessesautism,hischallengingbehaviourandmorespecifically hiscompulsiontoputfoodandobjectsinhismouthhadnotprompteda psychologicalassessmentoraconsistentprogrammeofbehaviour managementandriskreductionatthehome. Howeverthepanelfindsthatcommissioningandcontractinghas considerablyimprovedsince2005andthatthearrangementscurrentlyin forcewouldhavesignificantlyreducedtheriskofJessechokingandof previousincidentsbeingoverlookedasopportunitiesforenhanced individualisedplanningandriskmanagement.TheLondonBoroughof Barnetshouldensurethatthisimprovementismaintainedandthatithasa legallyenforceablecontractwithproviders,backedupbyindividualcare plans,inplaceatalltimes. So,whilethereweremanyfailingsthatledupto,andorhadaperipheral influenceonthecircumstancesofJesseMooresdeath,somehavebeen remediedandleadthepaneltothinkthathisdeathmightbelesslikelyto occurunderthecurrentarrangements.Butwithresourcesshrinkingthese improvementscouldeasilygointoreverseleavingothersfacingsimilar risks.

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Wethereforehighlightthesethreeareasinwhichprogressshouldbe consolidatedandmaintained, ContractingbytheLondonBoroughofBarnethasgreatly improved,thecarefundingcalculatorisusedtoensure consistencyandthedetailedcontractsetsoutclearand enforceableexpectations Acknowledgmentofdysphagiaandchokingasamajorcauseof deathforpeoplewithlearningdisabilitieshasbeenhighlightedby theNPSAandthishasledtothegreaterconsistencyinrisk management TheformationofacomplexcasepanelbridgingEnfieldSocial ServicesandEnfieldPCTholdsoutthehopethatpeoplewith challengingmedicalandbehaviouralconditionscanbereferredto appropriateprofessionalsforassessmentandtreatmentandthat compliancewiththisexpertadvicecanbemoreeffectively monitored:aservicethatisnotseekingand/ornotusingsuch expertinputshouldbeseenasafailingservice.

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