Outlook Care

Private and voluntary organisations · Social-care provider

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First report 15 Mar 2024•Latest report 15 Mar 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 100%
Concerns addressed: 1
Stated actions: 22

Concerns and recipient responses

Statements from Outlook Care linked to the concerns in each report. Select any concern, action or position to view the source wording.

15 Mar2024
East London
Concerns raised3
1. Lack of policing of homeless encampments in wooded areas
2. Lack of monitoring of homeless encampments in wooded areas
3. Failure to adequately supervise vulnerable persons
Actions described in response 6
1. Action
  Share team learning on evidencing engagement, learning and safeguarding practice for customers receiving community one-to-one support.
2. Action
  Conduct spot checks of community one-to-one support and provide further training or performance management where competency standards are unmet.
3. Action
  Issue video, written, poster and key-card guidance on one-to-one support and maintaining line of sight.
1. Action
  Review updated risk assessments covering Herbert Protocol, missing-person processes and community one-to-one support.
2. Action
  Strengthen staff duty-of-care learning and care-and-support policy focus on one-to-one support.
3. Action
  Use app-based daily risk assessments for every community support session and review results monthly for trends and concerns.
AI-generated summary

Sydney Alex Piper · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sydney Alex Piper, a 69-year-old man living in supported accommodation, left a mental health clinic while inadequately supervised on 23 February 2023 and was discovered deceased in a tent in Epping Forest on 24 March 2023. His death was caused by morphine toxicity, although it was not possible to determine how he was administered morphine or came to be at the site. The concerns were inadequate supervision of a vulnerable person and insufficient monitoring and policing of encampments, which increased the risk of fatal harm.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Outlook Care; that does not assign responsibility.
PFD Monitor interpretation
Lack of policing of homeless encampments in wooded areas
Wider context from the report
“2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Outlook Care; that does not assign responsibility.
PFD Monitor interpretation
Lack of monitoring of homeless encampments in wooded areas
Wider context from the report
“2. Mr Piper’s death was the latest in a series of deaths investigated by this court in which homeless persons have died in tents and encampments in wooded areas along the A406 and the periphery of Epping Forest due to high risk behaviours including, but not limited to, crush injuries, fire, third party assaults and drug misuse. The monitoring and policing of such encampments is, in the view of the court, lacking which increases the risk of fatal harm. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Outlook Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to adequately supervise vulnerable persons
Wider context from the report
“1. The support worker who accompanied Mr Piper on the day of his disappearance claimed that she did not constantly supervise Mr Piper as alternatively; she did not wish to crowd him, she was allergic to cigarette smoke, and finally that she needed to rest her legs. The witness accepted that she had neither read Mr Piper’s support plan, nor the relevant policies and procedures relevant to her duties that day. I am concerned that there is no clear evidence before me that the risk of a similar incident of inadequate supervision of a vulnerable person has been effectively mitigated. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share team learning on evidencing engagement, learning and safeguarding practice for customers receiving community one-to-one support.

Verbatim wording from the response
“• Shared learning in teams to review how we evidence engagement and learning for customers using 1:1 support in the community and safeguarding best practice.”

Source location
Response from Outlook Care
Page 2 · response
Published 20 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct spot checks of community one-to-one support and provide further training or performance management where competency standards are unmet.

Verbatim wording from the response
“• Spot checks on 1:1 support being delivered to service users in the community to check for both safety and quality as well as validating that our action plan is being implemented in practice, appendix 6. To date 21 spot checks have been completed and reported on to the Executive Management Team. Where performance of staff has fallen below our standards, staff are undergoing further training/performance management and cease to deliver community-based support until they reach the required competency level.”

Source location
Response from Outlook Care
Page 3 · response
Published 20 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Issue video, written, poster and key-card guidance on one-to-one support and maintaining line of sight.

Verbatim wording from the response
“• Guidance on the delivery of 1:1 support and the importance of maintaining a ‘line of sight’ has been issued, in form of video briefing, written guidance, posters, key facts cards issued to staff name badges, see appendix 7.”

Source location
Response from Outlook Care
Page 4 · response
Published 20 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review updated risk assessments covering Herbert Protocol, missing-person processes and community one-to-one support.

Verbatim wording from the response
“• Further review of updated risk assessments for all service users supported in relation to Herbert Protocol, missing persons process and delivery of 1:1 support in the community.”

Source location
Response from Outlook Care
Page 3 · response
Published 20 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Strengthen staff duty-of-care learning and care-and-support policy focus on one-to-one support.

Verbatim wording from the response
“• Supporting staff learning regarding their ‘Duty of Care’ including review of policy on Care and Support with a view to strengthen the focus on 1:1 support.”

Source location
Response from Outlook Care
Page 2 · response
Published 20 March 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Use app-based daily risk assessments for every community support session and review results monthly for trends and concerns.

Verbatim wording from the response
“• The use of a day to day, app based, risk assessment completed every time a service user is supported in the community, appendix 5. This process was implemented on 22 March 2024 and to date 1098 risk assessments have been completed and records stored securely, reviewed monthly by the Director of Care and Support to identify trends or areas of concern. To date the risk assessments have been completed by 458 staff.”

Source location
Response from Outlook Care
Page 3 · response
Published 20 March 2024
Open published response