“(brief summary of matters of concern) The concerns arising out of this investigation and…”

The coroner’s concerns

(brief summary of matters of concern) The concerns arising out of this investigation and inquest relate to the following key areas, Regulation 28 – After Inquest Document Template Updated 30/07/2021 a) Safeguarding b) Mental health provision c) Inter-agency communication – particularly where there is some doubt over who should provide additional support needed by a person. We heard in evidence that in the months after Lucy’s death, a Safeguarding Adults Board considered the case, but did not consider that a Safeguarding Adults Review (‘SAR’) should be undertaken. Evidence from Wokingham Borough Council was that they were not at that time aware of the number of safeguarding referrals that had been made. A decision was made (some six days before the inquest) that a SAR will now be conducted. The evidence of the Assistant Director of Adult Social Care was that this is likely to be completed within 1-3 months after the inquest. I have set out the issues / concerns that I have for each of the two recipients of this report, below. Reading Borough Council 1) Time scales for review and triage of safeguarding referrals. 2) Requirements to speak to the individual about whom safeguarding concerns have been raised. 3) Training around Section 42 and when a report meets the threshold for neglect or abuse. This training should also consider what options are available if a concern does not meet the threshold for a Section 42 enquiry. 4) Systems for making other involved agencies aware of safeguarding referrals and concerns. 5) In relation to each of the above points, whether RBC should reflect the above changes in formal (written) policy, as well as delivering training. 6) Improving interaction amongst agencies involved, and consideration of the threshold for arranging joint meetings to discuss service users, whether they meet Section 42 thresholds or not. The evidence we heard is that this is now being actively encouraged. Should there be written guidance about this somewhat subjective issue ? 7) Whether they consider that the resourcing of this service is adequate and safe. 8) Systems for auditing, and what will happen if the auditing reveals ongoing issues. Berkshire Health Care 1) How do the changes/proposed changes to systems (including the ‘One Team’ approach) make a difference? Specifically: a) Is the trust able to say with any confidence that a patient like Lucy would not be discharged from the crisis team without additional support, as she was on 2nd February? b) Is the trust able to say with any confidence that a patient like Lucy would be offered some support, whether by the crisis team or otherwise, in the situation that arose on the 15th February? 2) Do they consider that resourcing of these services is adequate and safe?

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2023-0206

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0