Jesse Moores Enquiry

7/31/2019 Jesse Moores Enquiry

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SERIOUS CASE REVIEW INTO THE

DEATH OF JESSE MOORES ONNOV 3RD2005

R E V I E W C A R R I E D O U T B Y H I L A R Y B R O W N , P R O F E S S O R O F S O C I A L C A R E ,

C A N T E R B U R Y C H R I S T C H U R C H U N I V E R S I T Y O N B E H A L F O F B A R N E T A N D

E N F I E L D S A F E G U A R D I N G A D U L T S B O A R D S .

PREFACEWhensomeoneusinghealthandsocialcareservicesdiesapreventabledeath,itis

rightthatasearchlightbedirectedontheirserviceanditsarrangements,including

factorsthathaveaffectedthesituationatoneremove.

ThedeathofJesseMooresattheageof26wasatragicaccidentbuttherehadbeen

sufficientsignalsabouthishealth,andabouthisservice,tosuggestthatitwasan

accidentthatcouldhavebeenprevented.Theeventsofthatdayandofthe

precedingweekswerepresentedandtestedincourt:theseriouscasereview

summarisedbutdidnotgobackoverthatprocess.Instead,asapanel,andas

participatingagencies,weaskedwhatwentwrong,andwhathasbeendoneto

remedythose

fault

lines,

so

that

we

can

use

hindsight

as

areference

point

against


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whichtointerrogatecurrentservices,askingCouldthishappennow?andWhat

elseneedstobedone?.

JesseMoores,wasayoungmanof26,withlearningdisabilities,autismand

TourettesSydrome,livingatTheChine,aresidentialhomerunbyRobiniaCare.He

was

a

much

loved

son

and

brother.

He

also

had

challenging

behaviour,

specifically

a

compulsiontoputobjects,whetheredibleorinedibleinhismouth.Hediedon3rd

Nov2005,havingchokedonahamsandwichthathehadgrabbedfrom,orbeen

givenby,anotherresident.Itislikelythathetookthesandwichtohisbedroom

wherehediedunobserved.Whenhewasfoundfirstaidorresuscitationwasnot

administeredandtherewasadelayincallinganambulance.Itisunclearwhetherby

thetimehewasfoundanythingcouldhavebeendonetosavehislife.

Thisresidentialunitexistedatthehubofamuchwidersystemofcommissioning,

funding,assessment,careandsupport.Hissocialcarewastheresponsibilityofthe

LondonBoroughofBarnet.Theyweresupposedtohaveadetailedcontractwith

RobiniaCare

specifying

the

quality

of

care

that

they

expected

and

the

way

they

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.

TheLondon

Borough

of

Barnet

who

were

paying

for

Jesses

care

should

also

have

organisedpropermonitoringofthisservicesincemisgivingshadbeenexpressed

throughrelatives/family meetingsatwhichconcernshadbeenraisedaboutthe

managementof,andstaffingarrangementsat,theChine(RobiniaCare)

Jesseshealthcarewastheresponsibility ofEnfieldPCT,coordinatedbyhisGPas

wouldbethecaseforanyothercitizen.Inadditiontothishehadrecoursetothe

CommunityLearningDisabilityTeamwithitsspecialisthealthcareprofessionals, he

wasseenbyapsychiatrist inrelationtohishyperactivityandbyaspeechand

languagetherapistinrelationtohiscommunicationneeds.Theservicedidnot

implementprogrammesthatweresuggestedtohelphimwithhiscommunication.

Noreferral

had

been

made

with

regard

to

his

putting

objects

in

his

mouth

or

the

riskofchoking. ThiskindofcasewouldnowbediscussedattheIntegratedLD


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ServicesComplexCasePanelandaplanofactiondecided.SadlyJessescase

occurredpriortointegrationofLDservicesinEnfieldwhensuchaforumdidnot

exist.

HE EVENTS LEADING UP TO JESSE S DEATHT

A N E S C A L A T I N G R I S K O F C H O K I N G

TheCourtTranscriptreferstothefactthatJessehadchokedfourtimesin

theweeksleadinguptohisdeathbuttheseincidentsdidnotleadto

concertedactionortoincreasedsupervision,norweretheysharedwithMr

Mooresastheyshouldhavebeen.Moreoverasafeguardingalerthadbeen

raisedinrelationtoanincidentwhereamemberofthepublichad

witnessedtwomembersofRobiniastaffusingunnecessarilyaggressiveforcetoremovesomethingfromJessesmouthinthepreviousyear.Twomeetings

were

held

and

an

action

plan

agreed

with

The

Chine

to

address

theserisksbuteitherthiswasnotimplementedand/ortheplacementwas

notproperlymonitoredinthelightofthis.

Giventhesefourpreviouschokingincidents,andtheprevioussafeguarding

intervention,Jessesdeathwasanaccidentthatstaffshouldhavebeen

preparedtopreventandonethattheyshouldhavebeencompetentto

respondto.Itisnotthecasethattheriskswerenotknown,butitisthe

casethattheyweredownplayedandthatthesharingofinformationwas

illcoordinatedandunfocussed.Inguidanceonthesematters,chokingwas

dealtwithasanissueformealtimes,separatelyfromJessestendencyto

pickupthingsandputtheminhismouthorhishabitofgrabbingfoodand

tingitawayfromthetableea .

HE DAY HE D ED T I

S T A F F I N G P R O B L E M S

AtthehousewhereJesselivedthereshouldhavebeenthreestaffonduty

onthemorningshiftbutonthedayJessediedtwounqualifiedand

inexperiencedcareworkershadbeenhiredonacasualbasisfroman

agencycalled

Synergy

because

there

were

insufficient

permanent

membersofstaffatthehomeoravailabletobeonduty,onewasworking

underanassumednameanditwassuggestedthattheHomesManager

mighthaveknownthis.Theregisteredhomemanagerwasworkingouthis

noticeatthetimestatingthathisreasonsforleavingwerethatthe

managementofRobiniaCarehadmovedexperiencedstafftoanother

homethattheyhadrecentlyopenedintheneighbourhoodwithoutbeing

replaced.Hesaidthatdespitenumerousrequestsfromhimtothe

companysseniormanagement,theywouldnotprovidesufficientstaff.He

hadnottakenhisconcernstotheotherauthoritiesconcernedwith

commissioningor

regulating

the

service.


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Ithasnotbeenpossibletorecovertheoriginalrotasbut,theinvestigators

whohadseenthem,andthephotocopiesdemonstratethattherewere

insufficientpermanentstaffandthattherotawasinastateoffluxwithlast

minutesubstitutionsacommonplacefeature.

The

only

experienced

member

of

staff

on

duty

that

morning

was

the

DeputyManager.Itemergedthatshehadasecondjobinaschooland

RobiniaCaredeemedthisabreachofhercontractasshehadnotdeclared

thispostonherapplicationform.Whensheleftthatmorningshesaidshe

wasgoingshoppingandtothePharmacyforTheChinebutshewas

actuallygoingtoherotherplaceofwork.Althoughshewasnotresponsible

forthelackofstaff,shewasondutyandformallyresponsibleduringthat

morningshift,andbyleavingsheabdicatedherresponsibilitytothethree

vulnerablepeopleinhercare.Heraccountoftheeventsofthatmorning,

andofherownmovementsandactions,keptchangingrightupto,and

ring thecourtcasedu , .

H O W J E S S E C H O K E D

Jessewasnotseendownstairsafter8.30amanditisnotclearwhenhe

grabbedthesandwichfromanotherresidentspackedlunch.Therewere

conflictingaccountsgivenastowhetherhechokeddownstairsandwas

carrieduptohisroom,orifhetookthesandwichtohisroomwherehe

chokedunobserved,thelatterseemsmoreconsistentwitheveryones

actionsafterthatpoint.OneoftheagencyworkersfoundJesseseemingly

leeponhisbedatabout915am.as

TH E I M M E D I A T E R E S P O N S E

Ondiscoveringhimlyinglifelessonhisbed,shecalledhercolleagueup

fromthegroundfloor.Heassumedthathiscolleaguehadfirstaidskillsbut

thefactthatshewasworkingunderanassumedname,withfalse

certificates,meantthatthiswasnotthecase.Neitherofthesestaffwere

briefedabout,orpreparedtorespondto,Jessesriskofchoking.Nordid

theyhaveinformationaboutwhattodoinanemergencyotherthantoring

theDeputyManagerwhohadleftthebuilding.Wecaninferthattheydid

notfeelauthorisedtoring999directlyandthepersonwhofoundJesse

wasactuallyinstructednottodoanythinguntiltheDeputyManage

returnedto

the

home.

Therefollowedanavoidabledelaybeforetheambulancewascalled.When

theparamedicsdideventuallyarrivetheyattemptedresuscitationbutit

wastoolate.InsteadoftryingtoclearJessesairwaysorplacehimina

recoverypositionitispossiblethattheworker,believinghimtohave

alreadydied,laidhimouthopingtoexpressrespectandkindliness

howevermisguided.

Thefactisthatnocoherentaccounthasbeengivenandthisislargelythe

responsibilityoftheDeputyManager,perhapswithcollusionfromother

staff.It

is

therefore

impossible

to

establish

whether

the

delay

in

summoningemergencyservicescontributeddirectlytoJessesdeath,orif


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thestaffwereactinginthebeliefthatitwasalreadytoolatetosavehim.

ThisrefusaltoprovideaconsistentaccounthasaddedconsiderablytoMr

Mooresdistressandanger.

Jessewaspronounceddeadat10.47amatChaseFarmHospital.Mr

Moores

arrived

at

the

hospital

at

about

11.45am,

as

soon

as

he

could

given

thelengthofhisjourneyandhewastoldthenthathissonhaddied.The

SocialWorkTeamLeaderatBarnetSocialServiceswastoldbytelephone

laterth ernoon.at aft

SECTION 2 THE ROOT CAUSE ANALYSIS Ascanbeseenfromthisreportandfromthepanelsdeliberations, thereis

no,one,simpleanswertothequestionofcausation.Manyfactors

convergedtoallowJessetochokethatmorningandtoblockanychanceof

theimmediatehelpthatwouldhavebeennecessarytoresuscitatehim.

Thissectionhastriedtoenumeratethoseactsandomissionsthatcame

togethertomakethiseventualitymorelikelybeforehedied,duringthe

crisisandthenthathinderedunderstandingafterwards.

BEFORE JESSE S DEATH Jessescompulsiontoputthingsinhismouthhadnotledtoa

formaldiagnosisorspecificbehaviouralprogrammeandnorwere

hisdifficultieswitheatingandchokingformalisedbyhealth

professionals

BarnetSocialServiceshadnotdrawnupapropercontractwithRobiniaCareandnorwasthereanymeaningfulcontract

monitoringorcomplianceactivity

ThiscontractdidnotspecifytheparticularneedsthatJesseMoorespresentedwith

RobiniaCarehadsubcontractedpartoftheservice(daycare)unofficially

ThecontractbetweenBarnetandRobiniadidnotprecludesuchsubcontractingsothatJessewasattendingthreeserviceswithout

propercoordinationandcommunicationbetweenthem

Insufficientnoticewaspaidtotheriskassessmentsandprevioussafeguardinginterventionthathadbeencarriedoutwithregard

toJesseshabitofputtingobjectsinhismouthandhistendencyto

takefoodfromotherpeoplebothofwhichledtoariskofchoking

notonlyatmealtimesbutatalltimes

TheserisksthathadbeensetoutinAugust2004werenotincorporatedintohiscareplansotheywerelostasstaffleftand

werereplaced.

TherewerefournearmissesinthemonthsleadinguptoJessesdeath:RobiniaCaredidnotreportoractuponthem


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DURING THE CRIS IS Therewasnoproperhandoverinstructingthetwoagencycare

workersabouttherisktoJesseandhowtosupervisehim

AnexperiencedmemberofstaffwasonlongtermsickleaveputtingpressureontheManagerandDeputyManagertocometo

workwhentheyshouldhavebeentakingtimeoff

TheDeputyManagerleftthehomeinchargeoftwoinexperiencedagencyworkers:thehomewasregisteredonthebasisofthere

beingthreeworkersonthemorningshift

OneoftheagencyworkershadonlyworkedatTheChineforafewdayspriortothisemergencywherehewasprimarilyadriverbut

hedidhavefirstaidtrainingandknewwhatshouldandcould

havebeendone:ifaformalhandoverhadtakenplaceitcould

havebeenmademoreexplicitwhowasonchargeduringtheshift

andwhowastotakechargeinanykindofmedicalemergency.

Carestaffwerenot,ordidnotfeel,authorizedtocall999directlytoensurethatJessereceivedimmediateresuscitationand

emergencytreatment

TheDeputyManagertoldtheworkerstowaituntilshereturnedwhensheshouldhavetoldthemtocallanambulance

immediately:itispossiblethatshebelievedJessehadalreadydied

ShethencalledtheambulanceonamobileandnotthelandlinefromthehousewhichwouldhavehelpedtheLondonAmbulance

Servicetohavelocatedthehome

Nofirstaidwasattempted Jessehadnotbeenputintherecoveryposition Staffgaveaconfusedaccountofeventstotheparamedics MrMooreswasnotcalleduntilalmost45minutesafterJessehad

beenfoundunconscious

BarnetSocialServiceswerenotcalleduntillaterthatafternoon

AFTERWARDS BarnetdidnotimmediatelycallEnfieldandaskthemtoinstigatea

SafeguardingAdults

Investigation

AninternalreviewwascarriedoutbytheAreaManagerforRobiniawithouttheoversightofEnfieldSafeguardingTeam

StaffatTheChinegaveconflictingandcontradictoryaccountsoftheeventsofthatmorning

TherewasconfusionaboutwhowastoliaisewithMrMooresduringthedaysandweeksafterJessediedandhowfartheycould

goinhelpinghimtoaccesstheinformationheneededtomake

senseofthesituation:heeventuallyreceivedhelpfromboth

socialservicedepartments(BarnetandEnfield)butthis,initself,

presentedsome

conflicts

of

interest


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WhenchallengedbyMrMoores,BarnetSocialServicesprevaricatedaboutanewcontractbeinginplace,thiswasnotthe

caseuntilNovember2008

BarnetSocialServicessoughttoevadebeingidentifiedwiththecasebywithdrawingfromajointpressstatementwhichleftMr

Mooresfeeling

unsupported

and

angry

RobiniaCarefailedtoreferthestaffconcernedtothePOVA1listuntilthiswasinsisteduponbyCSCI(nowCQC)

Thesafeguardinginvestigationwashaltedwhilepoliceconsideredtheoptions,thisdelayedmattersunduly

NoSeriousUntowardIncidentreportwascompletedregardingthehealthcareaspectsofJessespreventabledeath

TheLondonBoroughofBarnetdidnotseeklegalrecompensefromRobiniaCareonbehalfofMrMoores

Inthis

sad

story

many

things

went

wrong.

There

is

no

one

chain

of

events

tofollowbutatangledwebinwhichseparatestrandscanbeseentying

Jesseintothishighrisksituation. Moreover,hiscareraisedseriousdoubts

aboutthewayprofessionalshadworkedtogetherinthecommissioningof

hisservice,incareplanningandriskassessment,andinthedismissiveway

inwhichspecialisthealthcareandexpertadvicewasdiscardedbyJesses

service.Theserviceitselfwasoverreliantonagencystaffandrecruiting

fromaverydisadvantagedworkforce.Theconsequencewasthatthe

LondonBoroughofBarnetfailedtoprovidearesidentialplacementthat

couldmeetJessesneedsinasafeanddignifiedenvironmentandCSCI

failed

to

monitor

the

home

closely

enough

to

ensure

that

they

were

compliant ithminimumstandardsinrespectofstaffingandsafepractice.w

SECTION 3 ACTIONS TAKEN TO HOLD INDIVIDUALS

AND AGENCIES TO ACCOUNT

AC T I O N S T A K E N A G A I N S T T H E I N D I V I D U A LS H E L D

R E S P O N S I B L E

AprosecutionformanslaughterwasconsideredbythepolicebuttheCPS

werenot

persuaded

that

they

could

present

an

adequate

case

to

support

thischarge.SubsequentlytheManagerandDeputyManagerwere

prosecutedunderHealthandSafetylegislation.Theywerechargedwith

failingtocomplywithSections7and33oftheHealthandSafetyatWork

Act1974.Dueprocesswasappliedtotheiraccountswithafindingof

culpabilityinrelationtotheformerDeputyManagerandofnotguiltyin

thecaseoftheManager.Thisisimportantbutitisalsothecasethatduring

theinvestigationitbecameclearthatthisservicehadbecomeunsafefor

JesseMooresandthathisriskofchokingwasnotbeingproperlymonitored

1ThiswastheprecursortotheVettingandBarringSchemecurrentlyoperatedby

theIndependentSafeguarding Authority.


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ormanaged.Theseomissionswerenotthesoleresponsibility ofthetwo

staffchargedoroftheDeputyManagerwhowasconvicted.

AC T I O N S T A K E N A G A I N S T T H E S E R V I C E S R E S P O N S I B L E F O R

JE S S E A T T H E T I M E O F H I S D E A T H

RobiniaCare

as

an

organization

also

pleaded

guilty

to

charges

put

to

them

underHealthandSafetylegislationsothattheydidnotgothroughthe

courtprocess.Theywerefinedatotalof250,000.MrMooreshadurged

theLBofBarnettotakeactionagainstRobiniaonthegroundsofbreachof

contractonlytofindthatthecontractwasnotadequatelydrawnupand

thereforecouldnotbeusedtoholdthemtoaccount.

SubsequentlyMrMooressoughtanswersfromBarnetSocialServices,

throughalengthyanddistressingcorrespondence overthreeyears,about

thewayinwhichtheyhadcommissionedandcontractedJessescarefrom

thiscompanyandinsistedonbeingshownnew,revisedcontracts.Barnet

explainedthe

delay

in

implementing

anew

contract

as

aconsequence

of

ongoingdiscussionsabouttheimplementation ofapanLondonuniversal

contractforalllearningdisabilityservices.Whilelaudable,thisshouldnot

havebeenallowedtoblockthedevelopmentofanimprovedcontractfor

interimuse.Itisunthinkablethatlargeamountsofpublicmoneyshouldbe

committedwithoutabindingcontractualarrangement.ABarnetspecific

servicespecificationwasimplementedby2008whichstrengthenedthe

processesofaccountabilitybetweentheauthorityandprovideragencies.

TheNHShasnotconductedanSUIorotherreviewoftheirinvolvementin,

or

responsibility

in

relation

to,

Jesses

death.

It

is

unclear

whether

they

reportedhisdeathtotheNPSAasapreventabledeathinlinewiththeir

governancerequirements. ItseemshoweverthatJessesheightenedrisk

ofchoking,soclearlysignalledbythesepreviousincidents,hadnotledto

anycoordinatedassessmentorriskplanningasiscurrentlyrecommended

bytheNPSA.Hishealthcarewasnotthereforebeingadequately

coordinatedalthoughhewasbeingregularlyreviewedbyhisGP.

TheSafeguardingLeadinEnfield,workedcloselywithCQC(CSCIasitwas

then)overChristmasof2005toensurethatsufficientimmediatesafety

measureswereputinplacebyRobiniaCareoverthenextfewmonthsto

assurethe

safety

of

other

residents

but

the

provider

failed

to

reach

an

acceptablestandardandcommissionersfoundotherplacements,sothat

thehomebecamefinanciallynotviableandclosedinDecember2006.The

Panelareoftheviewthatinsufficientenforcementactionwastaken

againstthishomeandthatearlierproblemshadnotbeenrespondedto

withatoughenoughapproach.Thisisundoubtedlyacriticalareafor

debateasweenteraperiodoflighterregulationandeconomicausterity.


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SECTION 4 RECOMMENDATIONS AND CONCLUDING

REMARKS

Thefollowingrecommendations aretobeusedasthebasisforactionplans

foreachagencythathasbeenpartytothisreview.Thesewillberatifiedby

thePanelandmonitoredbothinhouseandbytherespectiveSafeguarding

AdultsBoards.

Action Agenciesaffected Timeframe

Amendreportableincidentsstipulation BarnetCommissioningand

ContractingTeam

Immediately

Within6months

Althoughparagraph2.7ofthePan

London2multiagencypolicyand

procedurestoprotectadultsfrom

abusestatesthatapoliceinvestigation

shouldtakeprimacywhenthisis

reviewedin2014thissectionshouldbe

expandedtostatethatsuchapolice

investigationwithaviewtoprosecution

shouldnotunreasonablyhaltother

agenciesgovernanceandmanagerial

actions sothatthesecantakeplacein

parallel,withsuitableprovisossoasnot

tocompromiseprosecution or

evidencegathering

PanLondonSafeguarding

EditorialBoard

2014

BothBarnetandEnfieldAdultSocial

Careshoulddevelopinformationand

intelligencegatheringsystemsthat

respondtoalertsaboutindividualsat

riskandtoconcernsaboutfailing

servicesandthesetwosystemsmust

speaktoeachother

LondonBoroughsofEnfield

andBarnettobesharedwith

PanLondonEditorialBoard

12 18months

Chokinganddysphagiashouldbedealt

withinlinewithNPSAguidelinesand

clientswithPICAshouldbesubjectto

multidisciplinaryassessmentandrisk

managementuntilsuchtimeasa

specificprotocolisdevelopedaround

thiscondition.

EnfieldandBarnetCLDTs 6months

Revisitthecontinuingcareguidance

andmakeitmorespecifictopeople

ChairtowritetoDHandNHS

Enfield

2

Protecting

adults

at

risk:

London

multi

agency

policy

and

procedures

tosafeguardadultsfromabuseProducedbytheSocialCareInstituteforExcellence

withthe PanLondonAdultSafeguardingEditorialBoard2011


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withautismandchallengingbehaviours

FunctionalAssessmentbyclinical

psychologistsshouldbethenormfor

individualswhohaveacompulsionto

putobjectsintheirmouthanddetailed

riskmanagement

plans

should

be

drawnuptogovernthewaytheir

everydaylivingsituationshouldbe

managedtoreduceandifnecessary

respondtoincidents

HBtoliaisewithBritish

PsychologicalSocietyand

withNICE/DH

12months

Negotiationsshouldbeginacross

LondonthroughthePanLondon

SafeguardingBoard,tosetupasystem

foralertinghostauthoritiestooutof

boroughplacementsbeingmadeon

behalfofindividualswhorequire

immediateand

/or

complex

health

care

arrangementstobeinplace:this

shouldincludeanypreviousincidents

ofchokingorchallengingbehaviour

thatrequiresassessmentbyaclinical

psychologist.

LBBarnettoliaisewithPan

LondonCommissioning

groups

PCTtodesign/modifythe

HealthAlertFormforthis

purpose

12months

Contractsshouldspecifythata

residentialserviceregisteraperson

withalearningdisabilitywithaGP

withinfourteendaysoftheirtakingup

residenceinanewplacement.


LondonCommissioning

groups

12months

Guidelineson

whistle

blowing

should

becirculatedtoallRegisteredHome

ManagersinbothBoroughsand

significantproblemsinrecruiting

sufficientstaffshouldbeincludedas

oneexampleofmattersthatshould

leadtoreportingofconcernsoutside

immediatelinemanagement

L.BBarnet

and

Enfield

3months

AtalocallevelCLDTtoensure

assessmentprocessappropriately

highlightstheneedsofpeoplewith

autismand

challenging

behaviours.

EnfieldandBarnetCTLD 6months

Progressincommissioningautism

specificservicesshouldbesharedwith

bothBarnetandEnfieldsSafeguarding

AdultsBoardsandnotedintheirannual

reports

LBofBarnetandEnfield 12months

Numbersandtrendsincommissioning

outofboroughplacementshouldbe

sharedwiththeSafeguardingAdults

Boardandmonitoredintermsofthe

implicationsforsafeguardingofboth

outplaced

but

also

incoming

placements

LBBarnetandEnfieldshould

addressthisonalocallevel

butlinkinwiththepan

LondonSafeguardingBoard

andADASSrelatingtotheir

guidanceon

ordinary

residence

12months


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Page 12

Itshouldbemadeclearinalljob

descriptionsandcontractsthatthejob

ofcarestaffistoengagewith

residents/serviceusersandnotonlyto

actasdomesticstaff.Thecontract

shouldspecify

that

they

expect

care

stafftoworkwithresidentsincarrying

outeverydaycooking,cleaningand

maintenanceandthattheyshould

prioritiseengagingwithserviceusers

overcleaningchores.

LBBarnetCommissioning 6months

Anominatedfirstaidershouldbe

designatedatthestartofeachshiftifat

allpossiblebutALLstaffshouldhave

basicfirstaidtraining.Homescannot

affordto

have

all

staff

trained

on

the

certificatedcoursessoshiftsystems

mayprecludethisrecommendation

actuallyhappeningbetterthatall

staffhavebasictrainingandalsoknow

abouttheuseof999emergency

services.

ProviderGroupstobe

informedthroughsubgroup

ofSAB

4months

Allhomesmustdisplayallemergency

contactdetailsonpublicnoticeboards.

Staffshouldhavebasictraininginand

anunderstandingofwhentocall

emergencyservice

and

know

that

they

donotneedtowaitfortheirmanagers

approvalbeforecalling999whenthe

situationisurgentand/orpotentially

dangerous.Amaximtoconveythisisif

indoubt,callthemout.

SABproviderliaisongroups

inEnfieldandBarnet

Clarifyarrangementsfortakingcontrol

ofserviceleveldocumentationaftera

deathorseriousuntowardincident


LondonSafeguardingpolicy

group

6months

Setinplaceaformalfamilyliaison

schemetosupportabereavedperson

throughoutasafeguarding

investigationanditsaftermathincases

thathavegivenrisetoparticularstress

anddistress.

LBBarnetandEnfield 6months

GuidanceontheconductofSUI

reportingshouldspecifythewhen

incidentsinvolvingpeoplewithlearning

disabilities,andcommunityservicesfall

withinthisprotocol

NHSEnfield 3months

Apolicyshouldbedrawnuptosetout

howhealthcareprofessionalsshould

respondto

missed

appointments,

or

to

aservicethatfailstoactonexpert

LBEnfieldCLDT tobeshared

withBarnetCLDT

12months


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Page 13

advicegivenortoimplement

recommendedtreatmentprogrammes

Linkinwithnationalinitiativesto

advocatefor,andsupport,thesocial

careworkforce,includingOxfams

recentcampaign

to

improve

the

workingconditionsofmigrantworkers

inthesocialcaresector

HBtoreportbacktoBarnet

SafeguardingAdultsBoard

12months

LinkinwithADASS,DH,theLondon

IndependentChairsnetwork,andother

nationalnetworkstofindwaysof

ensuringthatrecommendationsfrom

thisandotherseriouscasereviewscan

beimplementedonanationalbasis

LondonBoroughsofBarnet

andEnfield,CQC,HBasChair

ofthispanel

3years

CONCLUSION

AFTERWORD Thiswasanunsafeservicethatdidnothavetheexpertiseorresourcesto

assureJesseMooresbasicsafety.AtthetimeofJessesdeaththerewere

seriousdeficienciesinthecommissioningandcontractingarrangements

putinplacebytheLondonBoroughofBarnetandthesewereexacerbated

bydiscontinuityintheprovisionofsocialworksupport,afailuretoreport

concernsandincidentsonthepartofRobiniaCare,inadequaterisk

management

and

missed

reviews.

There

was

also

a

failure

on

the

part

of

EnfieldPCTtoprovideadequatespecialisthealthcareadviceandseeit

actedupon.Jessesautism,hischallengingbehaviourandmorespecifically

hiscompulsiontoputfoodandobjectsinhismouthhadnotprompteda

psychologicalassessmentoraconsistentprogrammeofbehaviour

managementandriskreductionatthehome.

Howeverthepanelfindsthatcommissioningandcontractinghas

considerablyimprovedsince2005andthatthearrangementscurrentlyin

forcewouldhavesignificantlyreducedtheriskofJessechokingandof

previousincidentsbeingoverlookedasopportunitiesforenhanced

individualisedplanning

and

risk

management.

The

London

Borough

of

Barnetshouldensurethatthisimprovementismaintainedandthatithasa

legallyenforceablecontractwithproviders,backedupbyindividualcare

plans,inplaceatalltimes.

So,whilethereweremanyfailingsthatledupto,andorhadaperipheral

influenceonthecircumstancesofJesseMooresdeath,somehavebeen

remediedandleadthepaneltothinkthathisdeathmightbelesslikelyto

occurunderthecurrentarrangements.Butwithresourcesshrinkingthese

improvementscouldeasilygointoreverseleavingothersfacingsimilar

risks.


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Page 14

Wethereforehighlightthesethreeareasinwhichprogressshouldbe

consolidatedandmaintained,

ContractingbytheLondonBoroughofBarnethasgreatlyimproved,thecarefundingcalculatorisusedtoensure

consistency

and

the

detailed

contract

sets

out

clear

and

enforceableexpectations

Acknowledgmentofdysphagiaandchokingasamajorcauseofdeathforpeoplewithlearningdisabilitieshasbeenhighlightedby

theNPSAandthishasledtothegreaterconsistencyinrisk

management

TheformationofacomplexcasepanelbridgingEnfieldSocialServicesandEnfieldPCTholdsoutthehopethatpeoplewith

challengingmedicalandbehaviouralconditionscanbereferredto

appropriateprofessionalsforassessmentandtreatmentandthat

compliancewiththisexpertadvicecanbemoreeffectively

monitored:aservicethatisnotseekingand/ornotusingsuch

expertinputshouldbeseenasafailingservice.

Documents

Jesse Moores Enquiry