Woman banned from all public buildings demands independent investigation after Hackney Council corrects safeguarding policy - thanks to her
PUBLISHED: 08:47 25 June 2019 | UPDATED: 09:48 25 June 2019
Hackney Council has corrected its safeguarding policy thanks to the woman it banned from all public buildings - who says she was trying to point out it didn't adhere to national legal standards.
Elisabeth Solomon has now questioned whether her mother Carol's death could have been avoided had the policy been correct in the first place, and has called for an independent inquiry.
Carol's body is decomposing in a fridge 15 months after her death because Elisabeth refuses to bury her until she has had a post-mortem. She died on March 10 after a catalogue of errors that saw her sent home from Homerton Hospital without being told her back was fractured; wrongly administered medication; and social workers taking weeks to act on various different safeguarding concerns that should have been dealt with within 24 hours.
Many questions remain unanswered and Elisabeth still has no idea why Carol ended up with second degree burns on her legs.
She believes her mother died because of multi-agency failings. But the council disagrees, and didn't refer her case to the coroner.
For months before her mother's death, Elisabeth tried to flag up that social workers in Hackney were failing to correctly implement Care Act policy. The Care Act was introduced five years ago to protect vulnerable adults at risk of abuse or neglect.
But rather than anyone taking note of her concerns, Elisabeth was successively banned from just about every organisation in Hackney including all council buildings, Homerton Hospital, the Citizens Advice Bureau, Hackney CVS, and the HQ of the patient watchdog Healthwatch Hackney.
She believes her mother should have been referred to the City and Hackney Safeguarding Adult's Board (CHSAB) for a safeguarding adults review (SAR) while she was alive, and after her death Elisabeth tried to refer the case herself.
A SAR is a multi-agency process that considers whether or not serious harm experienced by an adult at risk of abuse or neglect could have been predicted or prevented. The idea is to prevent death or serious harm in future.
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National legal guidelines state any person or service user should be able to refer a case for a SAR. But in Hackney, until policy was changed last month, only professionals or organisations were able to do that.
According to national legal guidelines there should also be an appeals process if a SAR is rejected. However, there wasn't in Hackney until Elisabeth pointed out the flaw in policy.
If the CHSAB rejects a SAR referral, the reasons why should be clearly stated.
In Elisabeth's case she still has no idea why her mother's SAR was rejected.
But again, corrected policy in Hackney now states that reasons should be given for a SAR rejection.
Ironically the independent chair of the CHSAB, Adi Cooper OBE, helped draw up the Care Act guidelines - but failed to implement it correctly in the borough she works.
Policy should have been updated last month, but the flawed document remained on the council's website until this week when the Gazette itself pointed out the error.
"The fact they've changed policy opens a new angle to ask questions of Hackney," said Elisabeth. "Who left the policy like that? Why haven't they said thank you to me? I'm not saying that with my ego, but why haven't they been speaking to me? Maybe I've got a point about my mum's case. Has anyone looked on how incorrect policy implicated on Mrs Solomon's life and why she died?
"Adi Cooper has rewritten that policy and she has not had the common decency to speak to me, or thank me for bringing it to her attention, or explained why she didn't do it herself five years ago." And she claimed: "The reason my mum died was because they didn't follow SAR guidelines.
"The fact the policy was biased indicates the attitude of professionals that work in the borough. That is key to my mum's story and key to ending suffering in Hackney. It was telling people: 'Shut up. You can't tell us anything.' That's discriminating against service users under the Equalities Act. It's disempowering and defeats the object of the Care Act which was to make safeguarding personal." The Gazette asked the council if an independent investigation into Mrs Solomon's death would be held, but they failed to answer. A council spokesperson said: "There has also been no change in policy, only a change in process, which allows people to appeal a decision over whether a SAR should be commissioned or not.
"This is the first time such a challenge had been raised and in view of this, the board did decide to review the decision, which was undertaken by Dr Adi Cooper. The board also decided to revise its process in relation to appealing any subsequent SAR commissioning decisions. The board has not received any concerns from anyone else in relation to any appeals process."