Case review’s special recommendations to agencies

TWELVE ORGANISATIONS were involved in the serious case review.

 These included: Northumbria Police, South Tyneside Council Adults Social Care, the Care Quality Commission, NHS South of Tyne and Wear Primary Care Trust, Northumberland Tyne and Wear NHS Foundation Trust, South Tyneside NHS Foundation Trust, the Coroner’s office for South Tyneside, Countrywide Care Homes Ltd, The Nursing and Midwifery Council, the Health and Safety Executive, Northern Doctors Urgent Care Ltd and the Independent Safeguarding Authority.



Inspect care homes on an annual basis.

Ensure all relevant staff are clear about roles and responsibilities in the safeguarding system to ensure information about concerns over services are shared in the most effective and timely way.

South Tyneside Council Adult Social Care

Ensure the council’s escalation policy is known and understood and address any communication gaps.

Train staff to recognise and address issues of concern.

Check care providers, specifically their recruitment, training and supervision systems and that they meet meet required standards.

Review safeguarding training to make sure “institutional abuse” is given a higher profile and to make staff aware of how complex and difficult this abuse is to detect.

Primary Care Trust

Undertake annual joint monitoring visits to care home providers.

Ensure Safeguarding Vulnerable Adults Training is mandatory.

South Tyneside Hospital Foundation Trust

Staff to be aware that repeated admissions to hospital of elderly patients should prompt a ‘trigger’ to ask whether the care home is managing the needs of the patient.

Nursing and Midwifery Council

Review the length of time taken to resolve disciplinary cases.

Ensure its role is more visible in care homes for staff and relatives.

Northumbria Police

When investigating a sudden death, to examine the care plan for the 48 hours immediately before for any omissions, deletions or alterations that suggests evidence of third party involvement. In such cases a Detective Inspector should be called to the scene.




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