Agenda item

Purpose: To receive the annual report of the Inquest Review Panel and to consider any findings or recommendations arising.

Melanie O’Rourke (Service Director, Adult Social Care, West Berkshire Council) presented the report on the Inquest Review Panel, which was established in 2022 in response to an increased number of cases where Adult Social Care was approached by the coroner’s office for information or as an interested party. The panel ensures governance, oversight, and learning from such cases to improve services and prevent future deaths where possible. It was explained that the panel met quarterly and was chaired by Melanie O’Rourke. It includes representatives from operational teams, safeguarding, legal, and insurance services. The focus is on identifying learning opportunities and improving practices.

During the debate the following points were discussed:

·         It was noted that the majority of cases reviewed by the panel involved themes such as substance misuse, homelessness, and mental health, often with interrelated factors.

·         It was confirmed that no discernible patterns have been identified in terms of specific wards or areas but monitoring continued.

·         A question was asked about the training provided to staff. It was explained that training focused on improving awareness of risks, recognising signs of substance misuse, and ensuring collaborative working across teams.

·         It was highlighted that a partnership learning event was planned to bring together mental health services, community mental health teams, and locality teams to improve joint working.

·         It was raised that Public Health, as commissioners of drug and alcohol services, had been invited to participate in panel meetings to ensure effective collaboration and contract monitoring.

·         It was reported that a new role, the Co-occurring Mental Health, Alcohol, and Drug (COMAD) worker, had been created to support individuals with complex needs. This role was jointly funded by Berkshire Health Foundation Trust, Public Health, and Housing. The postholder had recently started and was undergoing induction.

·         It was confirmed that of the five cases that went to inquest in the last year, the coroner provided advice in one case, recommending an upgrade to the recording system in a care home. This recommendation had been implemented.

·         A question was asked about whether staff were trained to administer emergency interventions, such as naloxone, in cases of drug overdose. It was clarified that this was the responsibility of the commissioned drug and alcohol service, VIA, which provided specialist training and support. Adult Social Care staff focussed on awareness and signposting individuals to appropriate services.

·         It was asked whether the panel also reviewed cases involving children and young people. It was explained that there was a separate mechanism for children’s deaths, chaired by the Service Director for Children’s Services. Both panels followed the same framework and guidance.

·         It was clarified that the panel reviewed cases involving any vulnerable individual, regardless of whether they were known to Adult Social Care. In some cases, the panel may not have prior knowledge of the individual.

·         It was noted that the panel’s increased activity reflected a proactive approach to learning and prevention. The aim was to prevent deaths wherever possible, even though the numbers were relatively small.

·         It was highlighted that the panel’s work had led to improved collaboration and learning across services, with a focus on prevention and improving outcomes for vulnerable individuals.

The committee thanked Melanie O’Rourke for the report and commended the panel’s work in identifying learning opportunities and improving services.