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Learning from Experience Database - Serious Case Reviews

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Gloria Foster (Surrey)

Mrs Foster was left alone for nine days without her essential privately funded care and support service when the provider company ceased trading. She died eleven days after being discovered by a visiting district nurse and her admission to hospital. Police investigations concluded the action or lack of action of any person did not meet the criminal threshold of wilful neglect or ill treatment. The actions involved, or rather inaction, were not intentional or deliberate. Nor can the employing council be shown, at senior manager level, to have criminally breached their duty of care. The SCR found that Mrs Foster would have benefited from better multi-agency care coordination and review from August 2009. Besides offering a potential improvement to the quality of her life this may have avoided her falling victim to events.  The provider failure protocol subsequently put in place by Surrey addresses the necessity to treat service closure as a significant occurrence demanding of focussed leadership. It includes, for example, the use of timed handover logs and scheduled debriefings that would have picked up the omissions that left Mrs Foster without home care for nine days.

Professional learning:

  • The need to have in place a Provider Failure Protocol which recognises service closure as a significant occurrence.
  • The need for clear policy and practice guidance regarding people returning home to improve multi-agency coordination of care.
  • The need for an access policy and procedure (for support health professionals who undertake home visits and need to gain entry) that combines the need for privacy, security and ease of entry.
  • The need to promote the use of assisted living technology in improving quality of life and personal safety.

2013 September Serious Case Review regarding Gloria Foster (Surrey)