Fern Foster Inquest – Safeguarding Adults Review

The Senior Coroner, Crispin Butler opened Day 10 of Fern’s inquest by welcoming people to court. He gave a warning about sensitive reporting of the circumstances around Fern’s death, most particularly about method. He said there was evidence to be heard this morning, then legal discussions would be made this afternoon, and he was anticipating he would give his conclusion tomorrow afternoon.

There was some discussion of submissions and additional statements that he said he would address with witnesses tomorrow. The coroner told the court he wished to read and place on record the fifteen recommendations from the Safeguarding Adults Review, before hearing the evidence of Richard Nash, the Service Director for Buckinghamshire Council Children’s Services.

The coroner said that the document was included in one of the bundles, from page 131 onwards.

I wanted to ensure, whilst the terms of reference and ambit is entirely different from the inquest that those recommendations were included, and where they touch on matters Mr Nash may be able to assist with, learning and implementation from Children’s Services perspective, we can hear that as well.

The coroner told the court that this was Section 5 of the Buckinghamshire Adult Safeguarding Review, and that Children’s Services were one of the participants of that overview report.

5.1 A range of formal recommendations were made as part of the rapid review and SAR [Safeguarding Adults Review] process for the improvement of systems and practice, subsequent reports … also made less formal comments and recommendations.

5.2 The board should review all recommendations with partner agencies within one year of publication of this SAR to ensure sufficient progress has been made.

5.3 [missed]

5.4 The review found there were gaps or absences of provision of services for autistic people and their families, in particular services which supported their mental and emotional health needs, and where there was no coexisting diagnosis of autism

Recommendation 1: Review commissioning plans for the provision of services for autistic people against national and local autism strategies by January 2024. Ensure timely access to advocacy [my paraphrase]. Improve service provision by 2026.

5.5 The review found the levels of knowledge in identifying and understanding the needs of autistic people were inconsistent.

Recommendation 2: Review current induction and CPD training and practice against key ASD guidance material by July 2023. With specific reference to reasonable adjustments. Revise CPD training to reflect the review by September (?) 2023, using people with lived experience of autism to deliver or contribute to training as much as possible.

5.6 Review found while was evidence staff changes may not always have been avoidable, there was a lack of evidence of the understanding of the impact of frequent changes of staff on a person in complex and challenging circumstances.

Recommendation 3: Further strengthen processes when there may have to be a change in relevant personnel … to ensure processes are not being applied over the needs of a person, for example moving to another service area, or for operational reasons. Adhering to the principles of Making Safeguarding Personal.

5.7 The review found pathways through services were not always clear to the user, their family and other agencies. There was a lack of evidence of personalisation in some circumstances. Process over person.

Recommendation 4: Review current autism referral, assessment and care pathways with key agencies party to this review including health, social care and housing. Includes specific analysis on the use of health passports to reduce the number of assessments.

Recommendation 5: Establish a joint protocol for autism assessment by September 2024. Convene a working group by June 2023.

5.8 This review finds frontline staff are not consistently aware of the learning from reviews or how to apply that to their practice.

Recommendation 6: Issue a 7 minute briefing to relevant staff by May 2023. To include specific reference to autism practice guidance, the SAR, the Green Light Toolkit and Red Flag Indicators.

5.9 As above, the review finds relevant staff are not sufficiently aware of relevant reports … and their findings … to improve outcomes for service users.

Recommendation 7: Agree a communication plan with multiagency briefing for maternity and perinatal staff of key MBRRACE reports and findings by September (?) 2023. Agree which other agencies should be included in the communications plan.

5.10 Review found learning from other reviews relating to use of, timeliness and quality of pre-birth assessments was not applied to this family.

Recommendation 8: Audit the use of pre-birth assessments against findings from this and other relevant reports [missed] and SARs by July 2023. Children’s Services to give assurance assessments are carried out in all high-risk cases by April 2024, and demonstrate an awareness of commonly occurring issues such as autism, domestic violence, and family dynamics.

5.11 Review found while suicide and self-harm features as a repeat theme in reviews and audits, partners would benefit from access to information about current learning/recommended practice improvements.

Recommendation 9: Conduct a joint agency review of suicide risk management in complex multi-agency cases with the aim of identifying multi-agency learning and actions from themes identified from suicides.

5.12 Review found while steps were taken by CSC (Children’s Social Care) to ensure meetings were accessible, further improvements can be made.

Recommendation 10: Review current information on child protection process by July 2023. Produce a simple leaflet in Easy Read by September 2023, to support autistic people going through child protection processes. Ensure this leaflet forms one part of an autism informed approach to communication and includes information on how to raise questions and concerns.

Recommendation 11: Review non professional support available to people in child protection processes by July 2023. Consider a buddy system or similar peer network support by September 2023.

5.13 Review found it was not possible to evidence that accessible and tailored information is available consistently for autistic parents … this was also a recommendation in Baby Q Serious Case Review. There was not sufficient evidence relevant recommendations have been implemented and embedded.

Recommendation 12: Review current information and support available to new parents with autism, against recommendations in Baby Q Serious Case Review and the findings from this review. Issue/re-issue Easy Read information to all such parents from July 2023.

5.14 Review found the pathway for people who had frequent admissions, presentation and complex needs was not always clear to services and the individual

Recommendation 13: Review current processes on high level revolving door admissions and case management by July 2023.

5.15 Review found the wider family required some ongoing support post bereavement and there was a lack of clarity around who would offer that.

Recommendation 14: Review the process for supporting families after a death or serious incident by July 2023. Consider the introduction of independent/no blame support regardless of litigation … including practical advice for matters such as financial support for funerals.

5.16 Review found a family in this situation may use parallel processes in order to try and be heard and get the support they require … complaints processes and … multi-agency review of a case often did not inform each other.

Recommendation 15: Assurance to be sought where there is a potential relationship breakdown with a family and/or parallel complaints process … is a process which shows how such cases are identified and reviewed, to include restorative discussion meetings with attendance from families, relevant staff and managers [missed end]

The coroner told the court that the independent author of the report was Martin Bradshaw and it was dated February 2023.

[The rest of the morning was spent hearing evidence of Richard Nash. I’ll try to report that later].

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