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Investigation and inquest
On 12 March 2018 an investigation was commenced into the death of William Lugg, aged 68 years old. The investigation concluded at the end of the inquest on 20 June 2018. The inquest found that Mr Lugg died on 6 March 2018 at his residence at Flat 29 Maude House, Ropley Street, London E2 following an unwitnessed fall when he was ascending the stairs at that address, which occurred on / by the morning of 3 March 2018. The conclusion of the inquest was a narrative one (see 4. below). The medical cause of death was found to be: 1a head injury.
Circumstances of the death
Mr Lugg lived alone and had not left his residence for several years. He suffered from severe depression. He was under the care of the Tower Hamlets Adult Social Care Team and received daily care visits from staff employed by the Careworld London care agency and also Meals on Wheels. From the morning of 3 March 2018 onwards, the Careworld carer and the Meals on Wheels personnel received no answer upon their daily attendances at the premises. This was unusual. Careworld did not contact the Tower Hamlets Out of hours service or the police over the weekend of 3 – 4 March 2018. They conveyed inaccurate information to Tower Hamlets on 4 and 5 March 2018. The premises were not attended until 6 March 2018 by Tower Hamlets Adult Social Care Staff, when police were contacted for the first time. Once entry was gained, Mr Lugg was discovered, deceased, having fallen down the stairs. It is not clear whether or not earlier intervention, following the fall, would have saved him.
Coroner’s concerns
(1) Tower Hamlet’s Failed Visits Procedure was poorly understood and not followed by Careworld staff, in particular (though not limited to): (a) the appropriate means of alerting Tower Hamlets to failed care visits that occurred during a weekend; and (b) use of the Tower Hamlet’s pro forma Failed Visit Record;
(2) Careworld’s own Failed Visits Procedure does not mirror or reflect aspects of Tower Hamlet’s prescribed procedure;
(3) Vital information regarding the identity of and contact details for the only other keyholder to the premises in this instance was not clearly recorded by either Tower Hamlets or Careworld;
(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made, leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff;
(5) Neither Tower Hamlets or Careworld’s Failed Visits policy gives any / any sufficient prominence to the possibility of involving the police if other attempts to confirm the individual’s welfare following a failed visit have proved unsuccessful;
(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making).
Information checked against the published report and official responses