Anthony Wilkinson · Prevention of Future Deaths report

On 10 April 2018 I commenced an investigation into the death of Anthony Wilkinson born on 31 December 1960. The investigation concluded at the end of the inquest on 26 March 2021. The conclusion of the inquest was Unlawful Killing. Anthony died as a result of

1a: Foreign Body obstruction of the airway

Anthony Wilkinson ("Tony") was diagnosed with Fragile X syndrome. He lived relatively independently with support for much of his adult life and was able to access the community and undertake hobbies and interests without too much difficulty for much of his life. His overall health started to decline in late 2017 and he began having investigations for dementia or similar neurological decline.

The primary symptom of this which was exhibited was of unusual and more erratic behaviours including aggression and physical and verbal confrontations. One additional issue which arose with Tony was some swallowing difficulties. This led to Speech and Language Therapy Assessments being undertaken in 2017 and 2018. The first regarded Tony has having behavioural swallowing difficulties which meant that he crammed too much food into his mouth or put food into his mouth without swallowing what was already in his mouth.

Speech and Language Advice in 2017 was that Tony should be supervised at all times when eating and should have a softened diet. This advice was never incorporated into Tony’s support plans or risk assessments by the care provider.

Tony was provided with a meal on 18 February 2018 which resulted in him choking and having to be admitted to hospital. The meal that he was provided with in February 2018 was in line with SALT advice from 2017 but resulted in a further referral to the SALT team. When SALT visited on 5 and 6 March 2018 it was apparent that there was a deterioration in Tony and that his swallowing difficulties were now due to a mechanical issue with his swallow. As a result, they advised that Tony should have a fork mashable diet and thickened fluids. Again, this was not incorporated into a support plan at Tony’s address for carers to access and utilise.

Staff did indicate that they were aware of the need for fork mashable diet and thickened fluids however the communications log showed variable compliance with the specialist diet.

The care provider advised that support plans were generated at the head office and was then printed twice with a duplicate copy taken to the resident's home address. The care provider also advised that they would collect the communication logs and important issues sheets along with some other documentation from the resident's file once a month to audit for compliance and recording standards and then archive these at Head Office. It was apparent that the care co-ordinator in Tony's case was on annual leave and sick leave in the two weeks prior to Tony's death and was not able to advise when the sheets had last been collected but when the police took Tony's record from his home address the communication logs only went back to 28 March 2018 (Tony having died on 4 April 2018)

The Police carried out an investigation into Tony's death and found that no criminal charges would follow his death as matters could not be proven beyond reasonable doubt. Of course, the coroner’s proceedings only require matters to be proven on the balance of probabilities even where that relates to a finding of unlawful killing.

Following the evidence at the inquest the jury concluded that Tony had been unlawfully killed. They were asked a series of questions which formed box 3 of the record of inquest which required unanimous yes or no answers. They were answered as follows:-

a. Were Stars Social Support Limited responsible for the care and support needs of Tony between 4 December 2017 and 4 April 2018? Yes

b. Was part of the role which Stars Social Support Limited had translating specialist advice into support plans and risk assessments for Tony? Yes

c. Following the SALT assessments of 4 December 2017 and 5/6 March 2018, did Stars Social Support Limited put in place a robust procedure to implement the advice provided in Tony’s support plans and risk assessments? No

d. Did the support plans for Tony which were at ████████ adequately reflect the risks posed to Tony following the assessment by SALT on 5/6 March 2018? No

e. Were the support plans and risk assessments at Midland Road between 5 March 2018 and 4 April 2018 adequate to enable staff to mitigate the risks posed to Tony as a result of his swallowing difficulties? No

f. Following the SALT assessments of 4 December 2017 and 5/6 March 2018, did Stars Social Support Limited put in place adequate and robust communications to staff caring for Tony so that they were aware of the advice? No

g. Following the SALT assessment on 5/6 March 2018 did Stars Social Support Limited senior managers review whether staff were implementing the advice? No

h. Were staff aware of the expectation that they would attend head office to review staff use support plans and risk assessments as part of their role in supporting Tony? No

i. In view of the SALT advice, was Tony provided with appropriate food when he visited the Manchester Airport pub with a support worker from Stars Social Support Limited? No

j. Was Tony provided with safe care by Stars Social Support Limited between 5 March 2018 and 4 April 2018? No

Following Tony's death, the Care Quality Commission inspected Stars Social Support. They attempted to do so in 2018 however the Police had seized a significant amount of documentation and therefore they believed that they were not in a position to carry out an inspection of the services at this time. As a result of that the inspection triggered by Tony's death was not until 13 February 2019 and the subsequent report was released in May 2019. This inspection found that the services 'required improvement' overall with breaches of the Regulations. This would automatically trigger the requirement for a re inspection within 12 months of the published report (therefore the next inspection was required by 8 May 2020) Due to the breaches of the Regulations found, Stars Social Support were also required to provide an action plan within 28 days of the rating to commence improvements. CQC state they did not receive any action plan from Stars Social Support Limited following this inspection.

CQC did not return to the Provider to inspect until August 2020 which they confirm was due to the pandemic and not entering providers to inspect during this time. To mitigate this CQC determined they would risk stratify the providers and those that were high risk would receive priority monitoring and be the first inspected when they were able to return to inspection activity. CQC did not rate Stars Social Support as one of their higher risk providers at this time.

When CQC returned in August 2020 and reported on this inspection in October 2020 they determined that the provider was now rated as 'inadequate' overall. There were further breaches of the Regulations at this time. Again, the provider did not provide an action plan following this inspection.

Although the advice which Tony was given by Speech and Language Therapy was not a feature of the inquest proceedings the SALT team have subsequently updated their advice and guidance sheets and I will return to this feature of the proceedings below.

Stars Social Support Limited

(1) Stars Social Support Limited have a culture which does not encourage transparency or embrace the duty of candour. This was evidenced throughout the inquest proceedings and in the lack of engagement with CQC during the inspection regime.
(2) Stars Social Support Limited do not utilise their own website to ensure that policy and legislative changes can be adequately and promptly shared with service users, their families, and staff.
(3) Stars Social Support Limited do not have appropriate policies, procedures and checks in place to ensure that updates to care plans are communicated to all staff caring for service users or that the correct care and support plans, and risk assessments, are in the service users home address.
(4) Stars Social Support Limited have implemented the use of WhatsApp to ensure staff are aware of updates to service users plans and they require staff to confirm they have read and understood the update prior to caring for an individual. Whilst this is a positive use of technology to support staff in caring for service users it is in itself a safeguarding issue to hold personal information about the service user on personal mobile phones; this is especially the case where there are not adequate policies in place around the use of personal phones by staff members.
(5) The use of the WhatsApp group adds in two risks of its own, the first is that there is an over reliance on this being the means by which service users care plans are updated and by default this ends up being the service users care plan. This makes it more likely rather than less likely in my view that support plans in the service users’ home will not be updated in a timely fashion.
(6) Secondly, visiting professionals are not able to access the WhatsApp group and therefore will not be in receipt of this updated information which may be important for some service users.
(7) There was no evidence that fundamental matters such as standard operating procedures for displaying SALT advice or allergy advice in a service users’ kitchen where all can see it have been implemented by the Stars Social Support Limited.
(8) There remained a lack of understanding about the mental capacity act and how that may affect the care delivery to service users where it meant that a carer or senior manager had to be the decision maker for specific aspects of their care such as nutrition or medication
(9) There is now a significant reliance on the Director updating all records and delivering care and undertaking audits whilst she improves the culture of the organisation. There was no adequate description of contingency plans in the event of sickness of this individual.
(10)The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date.
(11)I did not hear or see any evidence of any policy or procedure being in place at the Stars Social Support Limited which related to completion of risk assessments and care plans; where they will be kept; how they should be updated; who will look at them and where; what to do in the event that there isn't one; how documents should be presented; how technology will be used; how data will be safeguarded; how audits will be undertaken; how handovers will be undertaken. This list is not exhaustive it is simply a list of some of the areas I am particularly concerned about in this case however I have not seen evidence of any policies produced by Stars Social Support Limited despite asking specifically for this at the end of the inquest proceedings. I have seen only an induction booklet.
(12)I would like to see evidence of how Stars Social Support Limited will positively engage with Regulators and other bodies to enhance the quality of their services.

Care Quality Commission

(13)CQC did not take adequate steps to access records held by the Police or the provider in a timely fashion following Tony's death. This potentially created risk to other service users as the Regulator had not inspected the service promptly following a significant event.
(14)CQC too readily accepted the lack of an action plan from the provider and did not use this lack of engagement from the provider to increase the risk profile for this provider. Had they done so an earlier re inspection may have been triggered or further regulatory action. This failure may have exposed other service users to unnecessary risk of harm as a result of an inaccurate risk picture being provided by the CQC.
(15)CQC did not take into consideration significant relevant factors when risk assessing this care provider at the start of the pandemic leading to an inappropriate risk profile being established and an exaggerated level of confidence being placed in the provider to provide safe services to residents without appropriate monitoring and oversight from the Regulator.
(16)The report from the August 2020 inspection was inaccurate and misleading and may have caused service users to be added to this service where that ought not to be the case. The report published in October 2020 refers to their being no evidence of harm however there is a woeful lack of detail about the context of this within the report. CQC should review this particular report for this provider and also reconsider the way in which reports are written to ensure that they are not misleading and therefore dangerous. This includes either omitting from the report any comment about harm where there is clearly a context and evidence of harm to service users previously, which is open and live, but which does not form part of the inspection or very clear confirmation in the report that there has been evidence of harm which does not form part of the specific inspection report.
(17)Where CQC are required to decide whether evidence ought to be used for the basis of an inspection OR for regulatory action, they ought to ensure there is a consistent approach to this including the consideration of policies and standard operating procedures. This should be approached on the basis of safeguarding the majority of remaining service users from harm being the priority even where that means prosecutions for breaches of Regulation may be compromised.

South West Yorkshire Partnership NHS Foundation Trust

(18)The advice from SALT was not an issue in this case, it was the application of this advice which was the primary concern. I would like to commend the approach that the Trust have taken in learning from the issues which I raised at the conclusion of the proceedings and the openness with which the Trust have received the concerns I had. The guidance sheets which have been produced are still not clear enough and will lead to confusion including around the consistency description and a list of foods which can be modified or should be avoided. This needs to be reviewed to avoid confusion.