Magdalen Dwerryhouse

“The referral of the to 5 Boroughs Partnership NHS.”

“Greater Manchester Fire and Rescue Service provide home safety checks free of charge to persons at an increased risk of fire and the Fire Service has developed a register of individuals who are at an increased risk of fire. Had information regarding the deceased's condition been referred to the Fire Service she would have been included on this register and prioritised for home safety checks”

“Ihave concerns with regard to the following:- i. The systems and procedures within 5 Boroughs Partnership NHS Foundation Trust with regard to the arrangements of appointments with vulnerable individuals particularly when directions are given by a Health Professional, namely HEM in the case of the deceased”

“Irequest you to consider the above concerns and to review the following:- i. The arrangements of appointments, contact with members of the family and the procedures in relation to failed home visits with a view to immediate action to contact family members and original referrers to alert them to the failed visits and to establish the reason for the failed visit and to rearrange the visit as soon as possible”

“The Fire Service would have been prepared to attend the multi-disciplinary team meeting held at the 5 Boroughs Partnership NHS Foundation Trust on the 7" November 2013 to assist in assessment and any action to be taken in relation to the deceased but there was no contact with the Fire Service, who was not invited to attend”