Gerard Goodwin
14 Nov 2023 · Coroner Robert Cohen · Cumbria
The coroner's concerns
1. safeguarding concerns overlooked
“The Liaison and Diversion Team considered that there were safeguarding concerns in respect of Mr [name redacted] and referred him to the Adult Social Care team of Cumbria Council. I understand that the team in question now forms part of Westmorland and Furness Council.”
2. case closure without rationale
“After a social worker considered that a care assessment was needed the Reablement Team appear to be able to come to an alternative view and close the case without further discussion or rationale. In another case this might lead to a vulnerable person being disregarded.”
3. referral not generated
“the Closure Team noticed that the Reablement Team were seeking to close a case in which another social worker had recommended a Care Assessment. They sent the case to the 'Short Term Allocation Tray'. This should have resulted in a referral but that did not happen. I am concerned that in a future case a referral might not be generated and a person's needs overlooked.”
4. case deallocation without action
“Thereafter Mr [name redacted] case was allocated and de-allocated to a social worker within the space of one day, without anything being done. It is said that there is no note or explanation for this. I am concerned that, once again, the ability of a case to be allocated and deallocated within a short period and without anything having been done may enable a case to 'fall through the cracks'.”
5. systemic communication failure
“it is striking how many different teams and systems appear to co-exist and require mutual communication and cross referencing. I am concerned that the above narrative demonstrates that those systems do not function effectively. I am concerned that this exposes other vulnerable adults to risk.”