A support service commissioned by the Council failed to update its riskassessments and share key information with a service user in the weeksbefore they died. The NHS Trust that jointly provided the service then failed toinclude some key information about the service user's case in its internal review and mademistakes in its submissions to the coroner. The Council has agreed to show that the support service it commissions has sent its risk assessment policy to all its staff, along with the Ombudsman's final decision on this case.The Council has agreed to reiterate to all staff at the support service, the importance of sharing information as part of multi-agency working and updating risk assessments in response to key information such as hospital admissions and updates from family and carers.The Council has agreed to show that it has reminded staff at the support service of the importance of following up promptly on contact which indicates an increased risk to a service user, such as reports from concerned family members.The Council has agreed to demonstrate that the NHS Trust it commissions partly to provide the support service, will show that it has considered how to improve its processes for double checking information sent to coroners, to ensure against mistakes in documentation.The Council has agreed to provide evidence from the NHS Trust - which partly commissions the support service - to show it has changed its policy so that family members and carers are now routinely consulted as part of the Trust's internal reviews of cases where a service user has died.