Mr Warren · Prevention of Future Deaths report

On 3 February 2015 the Senior Coroner commenced an investigation into the death of Mr Jeffrey Warren The investigation concluded at the end of the inquest on 21 July 2015. The conclusion of the inquest was accident, the medical cause of death being (1a) bronchopneumonia (1b) broken ribs (2) hypothermia.

1. Mr Warren, who was born on 13 December 1928, was a tenant of Crawley Borough Council (CBC). He was vulnerable in that not only was he elderly he also suffered deafness. He had no family and no known friends nor were there any neighbours known to take any active part in looking after his welfare.

2. The CBC housing department were aware that Mr Warren was someone who would benefit from support. However Mr Warren was an independent character and reluctant to accept help. With no known family or friends to assist him or encourage him to take the facilities and support that was on offer to him it was left to those employed by public bodies to do so. It was the view of the allocated Tenancy Support Officer (TSO1) that Mr Warren’s vulnerabilities were such that he ought to move to a sheltered housing scheme, however he declined this when offered. When his gas heating and cooking equipment was condemned in March 2014 he declined an offer of having central heating installed. He was therefore provided with two electric heaters by CBC.

3. Mr Warren’s case was allocated to the CBC Tenancy Support Team. The tenancy support officer (TSO1) described how one of the particular tasks of the tenancy support team was “to engage people”. TSO1 managed to achieve some engagement with Mr Warren, including taking him shopping to purchase a microwave. She stated in evidence that she believed she should be seen for support monthly. However she changed post in April 14 and her replacement recorded Mr Warren’s case as “case semi closed” on 28 April 2014.

4. Mr Warren was however referred to the “Older Persons Support team”. TSO1 informed the court that the rationale for the referral was that this team could visit Mr Warren more regularly and should try and engage him in accepting services. Mr Warren was reluctant to accept help and so would need extra effort to try and engage him. However the evidence was that after meeting him once in August 2014 Mr Warren was also discharged from that team.

5. Mr Warren was seen briefly again by TSO1 in December 2014 when he agreed to be referred to a service that supports those with sensory impairments and also agreed to the placement of a fire alarm in his flat.

6. On 14 January 2015, after having visited his flat to fit the alarm, the fire officer reported to CBC by email that the flat was unsafe in that the electric heater provided by CBC now had a broken leg and was leaning against non-flame retardant furniture. Replacement with an oil heater was suggested. This electric heater clearly created a continuing fire risk at the property, but this was neither noted as an urgent risk by CBC nor treated as such.

7. On 21 January TSO1 in discussion with her manager determined that a “vulnerable adult referral” known as a “safeguarding alert” should be made to West Sussex County Council Social Services (WSCC) because CBC were “very concerned for Mr Warren’s health particularly given the cold weather”.

8. That safeguarding alert was received on 21 January by WSCC, although it was not allocated to a social worker (SW1) until 26 January.

9. On 27 January SW1 decided that she would contact the police to request a welfare check. She informed the police that there was no immediate concern for Mr Warren and so a check could be made “in the next couple of days”. The police call handler pointed out to her that this type of welfare check was not normally a service provided by police – nevertheless, the police agreed to conduct a non-urgent ‘neighbourhood policing team’ visit.

10. A letter was sent to Mr Warren by SW1 on 28 January seeking his consent to refer him to the “prevention assessment team”. SW1 then discharged him from her team’s caseload.

11. The evidence of SW1 was that she was relatively new in post at the time and was unaware of the criteria applied by police for welfare checks or how the police graded the urgency of checks. She informed the court that neither before or since these events had she been given any training or provided with any information regarding when it is appropriate to use the police to conduct welfare checks or the protocols the police are then likely to use when categorising the urgency of calls made to them by social services. SW1 stated that although she could have requested a more urgent check to be conducted by a Social Worker from a locality team she referred to police because she thought it was unlikely that the WSCC locality team would have accepted the referral of Mr Warren because he would have been perceived to have had mainly housing needs.

12. On 29th January members of the ‘neighbourhood policing team’ conducted the non-urgent welfare check as requested and found Mr Warren deceased at his home. His house keys were in the front door and hence anyone attending his flat sooner could have gained access and found him sooner, although it is not possible to establish when he died.

13. It appears, from the circumstantial evidence of the dates on his shopping, that Mr Warren had fallen at his home on or around 24th January and was immobile on the floor with a number of broken ribs. Whilst lying on the floor he contracted bronchopneumonia and he also had physical signs associated with suffering hypothermia. The medical evidence was that he would have suffered distress, pain and stress.

14. No internal review of the events surrounding Mr Warren’s care and his death has been conducted by either Crawley Borough Council or West Sussex County Council. At the inquest hearing the Borough Council claimed to be in the process of conducting such a review, but it appeared that the key staff involved in the events were neither aware of that review nor had they, as yet, been interviewed or consulted as part of the review.

(1) That neither CBC nor WSCC have a yet undertaken any formal review of this case despite the death of someone known to both organisation and subject to a safeguarding alert at the time of his death. An opportunity to learn lessons from the above events has hence been delayed and potentially been lost.

(2) That Mr Warren had a potentially hazardous electric fire inside his home that had been supplied by his landlords (CBC) and that was left in situ from 14th January up until his death despite notification of this to the housing authorities;

(3) That WSCC Social Work staff sought to use police resources to conduct a non-urgent social welfare check, rather than allocating that check to an appropriate council employee;

(4) That WSCC Social Work staff are not aware of, given any training regarding or provided with any information about the criteria likely to be applied by police for conducting welfare checks and/or the circumstances in which it is or is not appropriate to ask the police to conduct a welfare check.