Emma Turner

1. 1. lack of information sharing between services

   “It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in [the deceased]'s best interests.”

2. 2. lack of connectivity between information systems

   “The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in [the deceased]'s care.”

3. 3. inappropriate safeguarding referral form for learning difficulties adults

   “safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery. Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since [the deceased]'s death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise.”

4. 4. delayed safeguarding team response

   “As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way.”

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