Surrey County Council workers suspended following damning report into death of starved pensioner Gloria Foster

A serious case review published today found Gloria Foster, 81, from Banstead, was left alone for nine days after her care agency was shut down by immigration police on January 15.

To read the full report click here Serious-Case-Review-GF-Executive-Summary-Final.pdf.

Sutton-based Carefirst 24 was contracted through Surrey County Council to look after Mrs Foster who depended on daily carer visits to supply her with food, water and medication.

The Surrey Safeguarding Adults Board report found Mrs Foster’s name was on the client list seized by police during the raid but she slipped through the net.

After listing a whole series of failings which contributed to Mrs Foster's death, the serious case review panel recommended that county council should take disciplinary action in relation to those failings.

The recommendations include action on how the client lists were used, the absence of any record of a call being made to check on her welfare and the veracity of record keeping of key events.

But it said the failures "were not intentional or deliberate" and decided that senior managers at Surrey County Council had not criminally breached their duty of care to Mrs Foster.

Police have already decided there is no case for criminal proceedings to be brought against anyone involved.

The board also made a number of recommendations including setting up a regular forum where various agencies can meet to share information and safeguarding concerns and holding an exercise to test procedures if an agency fails.

The report concluded: "A serious mistake seems an inadequate description of what happened. But leaving aside all the ‘what ifs’, that is exactly what happened.

"Certainly a number of professional omissions were made by a social worker at the Reigate and Banstead office, ones which seem rooted in false assumptions and left unquestioned at supervisory level.

"It is important that Surrey Adult Social Care continue to work to ensure that there are no shortcomings that contribute to or make mistakes more likely to happen."

Council: "Very sorry"

Surrey County Council’s strategic director for adult social care Sarah Mitchell immediately announced that a social worker and a team leader had been suspended and face disciplinary action.

She said: "We are very sorry for our failure to help Gloria Foster to get the support she needed.

"This report points out we should have done more and we completely accept that.

"While we have already made changes following this dreadful case we’ll now act on these findings to do all we can to prevent anything like this happening again.

"Two members of staff have been suspended and we’ll be taking disciplinary action in light of these findings."

The senior operational lead for the locality team claimed to have called Mrs Foster on January 16, but said she only recorded the call on January 25 - the day after Mrs Foster was found.

She said: "Unfortunately I did not put this note on AIS at the time I rang as I was busy setting up emergency care for other service users who had the same care agency.

"I did ring this lady but there was no reply. I assumed which I probably should not have done that as a self-funder she was able to arrange her own care, in hindsight this lady should have been visited, this was an error on my part."

But police have confirmed she had no incoming calls from the social workers or any other agency.

Report: Bed was sodden

On January 24 a nurse found Mrs Foster in a collapsed state and called the GP who rang for an ambulance.

The review said: "The notes indicate that Mrs Foster was in a very poor physical state.

"She was cold, lying partially off her bed which was sodden with urine and faeces and she appeared dehydrated with cracked lips.

"The ambulance crew were unable to record a blood pressure or find a radial pulse (wrist) indicating that her blood pressure was extremely low."

Mrs Foster was taken to Epsom Hospital where she died eleven days later.

The board’s independent chair, Simon Turpitt said: "There are certainly lessons to be learned here and by implementing the actions recommended, we are looking to ensure the circumstances which caused Mrs Foster to be without care for several days can be prevented from happening again."

Her friend Ann Penston described Mrs Foster ‘gregarious’ and said she would sit down and chat with anybody. Mrs Foster lived alone in Banstead and enjoyed travel, bridge, the theatre and tennis.

Recommendations by the Surrey Safeguarding Adults Board:

1. Consider all the recommendations of the agency IMRs collectively and sort them into a practical programme of work such that partners can be accountable to each other for their completion.

2. Request Surrey County Council to ensure that its disciplinary actions related to the care of Mrs Foster include investigations of:

i) how the key safe and client lists supplied by the Metropolitan Police prior to the raid were made use of by Surrey Adult Social Care 

ii) the absence of any record in their telephone systems of a call being made to Mrs Foster to check her welfare

iii) the veracity of recording of key events.

3. Prepare multi-agency guidance on best practice in recording

4. Advise all safeguarding professionals chairing meetings, in Sutton and Surrey, of the importance of having the right people in attendance, that clear and concise minutes are written and that the right actions are taken and known to be taken.

5. Ensure that partners agree a clear policy and practical arrangements for multi-disciplinary assessment, review and care coordination for people with complex needs and long term conditions - irrespective of their funding, current care package or with which agency the need arises.

6. Request Epsom and St Helier University Hospitals NHS Trust to review its policy and practice regarding people returning home to improve multi-agency coordination of care.

7. Suggests that the Community Matron and Virtual Ward service has continued funding and investment to develop and embed the service on a long-term basis and is appropriately commissioned with key performance indicators that lead to the right outcomes.

Further that this service is continued to be promoted amongst GPs, health and social care professionals.

8. Create a regular forum where partners can bring, share and discuss data, information and intelligence about safeguarding concerns with service provider organisations in the spirit of sector-led improvement.

9. Test the provider failure protocol with a view to establishing multi-agency ownership 10. Develop a simulation training exercise around the provider failure protocol as part of leadership development.

11. Advise Surrey County Council to continue its focus on ensuring that it’s organisational and social work cultures are ones that develop and sustain best practice.

12. Consider carrying out an audit of organisation and profession specific Mental Capacity Act training to see if there are any gaps requiring attention.

13. Support health professionals, who undertake home visits and need to gain entry using a key safe number, to develop an access policy and procedure that combines the need for privacy, security and ease of entry.

14. Promote the use of assisted living technology in improving quality of life and personal safety.