"During the inquest I heard from the carers who worked with Mr Godderidge. They reported to me that when concerns are raised about a service-user’s capacity there is not reliable and routine liaison between Adult Social Care and the care providers. I am concerned that this gives rise to a risk of future deaths. Care workers are very likely to see a service user more often than others. They have a particularly valuable perspective as to a person’s capacity. If their observations are not being considered then opportunities to provide care to vulnerable people may well be missed.
Mr Godderidge’s carers also reported to me that in their experience consideration of capacity by Adult Social Care does not always reflect the possibility that a person’s capacity may be variable and fluctuating. I am concerned that this gives rise to a risk of future deaths if a person is considered on a ‘good day’ without understanding that their presentation fluctuates substantially over time."