Well I feel compelled to comment on another death in the hope that some speedy lessons learnt may reduce the risk to others.
You can read some of the background on the BBC website here and here. I won't go dwell on the story but a few lessons occur to me based on what I have gleaned from the media reports:
- If you are providing a personal care service to the vulnerable, a risk worth considering could be, how do you ensure that individuals who personally deliver the service to the vulnerable, have the credentials? In the case in question it appears there may have been an issue of illegal workers and fraud. There are some similarities here with the Apple case when a third party was providing workers to a provider but the third party could not be relied upon to make sure the staff provided were appropriate.
- If a provider is being relied upon to provide essential services, a risk worth considering may be, how can you quickly be alerted if the provider ceases to supply at short notice?
- Linked with #2, a risk worth considering may be, if you need to find an alternative source, almost instantly, how do quickly can you get the new service be put in place? In this case it appears that the UKBA raided the providers office, the service ceased and the council put in place replacement services the same day.
- If you need to migrate service to a new provider at short notice, a risk worth considering may be, how do you ensure that the transition takes place at no risk to the recipient?
- When you are providing a personal service, on which recipients are dependent upon, a risk worth considering may be, if there is a failure in provision of personal support, how will you know?
Don't get me wrong, I am not suggesting for one minute that the council in question or indeed procurement or the commissioners are in the least bit culpable, I am merely highlighting some personal lessons learnt from this tragedy.