The Strategic Director, Health and Wellbeing and the Strategic Director Children’s Services will submit Document “O” which reports progress on the Bradford Safeguarding Children Board (BSCB) and the Safeguarding Adult Board (SAB).  The report outlines in brief the main areas covered by the annual reports and highlights areas of focus where joint approaches to policy and practice are in operation or are being considered for development across children’s and adults’ safeguarding arrangements.

Recommended-

That the Board receive the annual reports of the Bradford Safeguarding Boards.

                                                            (Bernard Lanigan – 01274 432900)

The Strategic Director, Health and Wellbeing and the Strategic Director Children’s Services submitted Document “O” which reported progress on plans made by the Bradford Safeguarding Children Board (BSCB) and the Safeguarding Adult Board (SAB) in 2015-16.  The report outlined in brief the main areas covered by the annual reports and highlighted areas of focus where joint approaches to policy and practice were in operation or were being considered for development across children’s and adults’ safeguarding arrangements.

Safeguarding Adults Board

The Chair of the Safeguarding Adults Board (SAB) referred to high numbers of referrals from care homes in 2015-16 and reported that SAB wished to focus on:

• Commissioning for quality across the sector, and may bring this issue back to Health and Wellbeing Board at a later date.

·        It was acknowledged that there are safeguarding issues which overlap between children’s and adults’ safeguarding including managing risk as young people move into adulthood,

·        SAB welcomes the Mazars report on the Southern Health Trust and its wider review of unexplained and premature deaths of people within mental health or learning disability services.

·        The two Safeguarding Boards would be working together to respond to the areas of abuse outlined in the 2014 Care Act such as Female Genital Mutilation and modern formsof slavery.

• SAB would like to see the 2017 revision of the Health and Wellbeing Strategy describe what good personalised care services was, primary care and acute services looked like to ensure there was whole system understanding for staff ; so that the public and staff could understand what personalised care was.

Members made the following comments:

·        The Chair of the Board emphasised the importance of providing good personalised care that meets needs as early as possible.

·        Public Health acknowledged that the Joint Health and Wellbeing Strategy could provide tools to help commissioners decide what to provide and how best to provide it.

·        It was reported that the Risk Enablement Panel was an open and transparent process to share issues and reduce alerts relating to personal care.

·        It was acknowledged that we need to improve the quality of care and that personalised care is often the least risky for individuals but the most challenging to commission. Adult Social Care will be looking at ways to address care needs and concerns about care earlier, to pre-empt safeguarding alerts by working with people and providers to develop a quality premium that goes beyond the Care Quality Commission judgements.

·        Members expressed concern after reading the Mazars report on the enquiry into the Southern Health Foundation Trust that we need as a sector to ensure that vulnerable people were receiving appropriate healthcare and were not dying prematurely as a result of poor care.

·        It was acknowledged that the District had a good track record on not using out of area placements for people with Learning Disabilities.

A detailed presentation was provided to the Board by the Director of Health at Mazars (External Auditors) on the findings of their enquiry into the deaths of people with learning disability or mental health at Southern Health Foundation Trust; she reported on the failure of the trust to investigate and learn from the deaths of patients; particularly those receiving care in its older people’s, learning disability and mental health services; the Quality Care Commission’s report due to be published on 12^th December would highlight the failures of the Trust and would be a good tool for other Trusts to use to reflect on and improve their own response to premature and unexplained deaths, particularly to recognise that investigations need to be multi-agency.

The Board heard case studies of people with learning disabilities who had died and their deaths were ruled as natural causes but could have been avoided if appropriate care and healthcare processes had been in place; and on the following:

·        The South Health Trust enquiry showed that the average age of death for people in its care was around 56 years old, for both people with learning disability and people with mental health needs.

·        Mazars had also conducted a broader review of  the NHS response to deaths in care and hospital settings and found that most deaths were judged to be as a result of natural causes, a relatively small percentage were properly investigated. Without proper investigation many opportunities to learn lessons, to improve practice and to improve health and wellbeing outcomes for vulnerable people were being missed.

·        In Bradford District there were between 600-1000 deaths annually for people with learning disability  or mental health needs, an increase from 500 per year several years ago (precise figures would be available from Mazars in the New Year). some would be for people aged 65 and over; some would be deaths from natural causes.

Questions and issues for the Board member organisations to reflect on included:

·        Was the health and wellbeing sector clear about where the responsibility lied to investigate premature or unexplained deaths?

·        Could the Local Authority and the CCGs identify how many clients with learning disability died in any one year – as focusing on this issue and getting it right for people with learning disability would help to get it right for everyone else.

·        Authorities needed to identify and report deaths accurately; investigate unexpected deaths properly and without delay; needed to look at meeting obligations to others; authorities needed to learn from deaths; organisations needed to be transparent and open in how cases were reported and investigated.

The representative from Mazars emphasised the importance of reading the CQC report when it was released as it would address a number of issues including system-wide issues that Local Authorities and NHS organisations would need to address, including to ask questions about how the health needs of people with mental health needs or learning disabilities were being met, particularly where challenging behaviour may be masking physical health needs where people could not for example say that they were in pain and that families and carers had the broadest knowledge of the health needs of vulnerable individuals and the longest view of the timeline of their life and health treatment.

Members thanked the representative from Mazars for the informative presentation and acknowledged that there was a huge amount of work that needed to be undertaken to ensure that we understood and learned from premature and unexplained deaths to improve healthcare for vulnerable people. This would be addressed by reviewing the current position and making recommendations for change, working better with families and ensuring that we had a robust system that shared information effectively. It was agreed the Integration and Change Board would lead a review and report back to the Health and Wellbeing Board at its meeting in May.

In response to a Member’s question it was reported that information on the number of deaths within people with mental health and learning disability in the district compared with other authorities would be available after Christmas.

Bradford Safeguarding Children’s Board (BSCB)

It was reported by the Chair of BSCB that Paul Hill, manager of the Children’s Safeguarding Board had left the Authority and that post was vacant at the moment but interviews had taken place; there were currently 511 children subject to child protection plans; two Serious Case Reviews would be published shortly; and there was a national review being undertaken of Safeguarding Boards. Child Death Overview Panels and how they were organised would also be looked at; the legislative process was likely to be very slow so the work of the panel would continue as normal; the Board had good partnership working which added enormous value to its work.

In response to the Chair’s question it was reported that the work of the Board was good in comparative terms but there was no room to be complacent as there was always room for improvement. 

Members stressed the importance of all schools complying with child protection regulations and raised concerns that 20% of schools had not returned their welfare and training needs analysis.

A Member suggested that schools that did not respond to the analysis needed to be reported to the Regional Schools Commissioner.

Resolved-

(1)       That the Board receives the annual reports of the Bradford Safeguarding Boards.

(2)       That the presentation from Mazars of its investigation of deaths of people with Learning Disability or Mental Health at Southern Health Foundation Trust be provided to Board Members.

(3)       That the Integration and Change Board (ICB) consider the findings of the Care Quality Commission (CQC) Report on Southern Health Foundation Trust when it is published, and work with Mazars to consider the learning from information on deaths of people with Learning Disability or Mental Health in Bradford District. That the ICB undertakes this work in the context of: the report of the national Confidential Inquiry into Premature Deaths of People with Learning Disability (2013); the work of the District’s Child and Adult Death Overview Panels and the work of the Coroner. That the ICB consider the role for person-centred care and advocacy in establishing good practice and report back to the Board in May 2017.

(4)       That the Chairs of the Safeguarding Board for Children’s and Adults and the Voluntary and Community Sector Representative be involved in considering the piece of work outlined in 3 above.

Action:          Strategic Director, Health and Wellbeing