Safeguarding Adult Reviews (SAR)

Background

Jo, 34, was a young woman living alone, with her companion dog, which was Jo’s protective factor. She had two siblings, and at the time of her death, was in touch with her father, possibly her sister, but not her mother. Jo was a talented artist who had struggled with mental health problems, for about 18 years. A bright, intelligent woman was regarded as a good neighbour and wanted to help others.

She regularly expressed suicidal ideation and had attempted suicide from 2018 to 2020 on eight known occasions, having made a very serious attempt in 2017, when diagnosed with bipolar disorder and Post traumatic stress disorder (PTSD). In September 2019, she was diagnosed with Emotionally Unstable Personality Disorder (EUPD). Seven safeguarding referrals had been made during this period, by various services about her suicidal intent; thoughts or actions.

As a child, Jo had been sexually abused for several years. She disclosed this to a counsellor at the age of 16, but information was not shared with Children’s Services. She decided to report the historic child sexual abuse to police, which led to an investigation and was filed, twice owing to a lack of substantive evidence. Jo struggled to accept the decision, developing a rapport with the Senior Investigating Officer, and disclosed her mental health issues and the impact of the Police decision.t of the police decision.

Incident

Jo attended Emergency Department (ED) on many occasions, mainly owing to her mental health issues, but was deemed to have mental capacity. She had been known to use alcohol and drugs to cope with symptoms but had been largely abstinent prior to her death.

On 10th March 2020, following a serious illness, her dog was put to sleep and Jo went into crisis, and she attempted suicide. She survived, called for an ambulance, and after ED attendance absconded; returned by police and stayed overnight.

On 26th March 2020, Jo had completed suicide.

Support for families post suicide

Families in Stockport would benefit from a more proactive approach to post suicide family support, given that suicidal death causes severe, family distress, and carries a very traumatising and long-lasting impact.

The confidential Greater Manchester Bereavement Service is there to listen and help find the right support for anyone bereaved. The service includes dedicated suicide bereavement practitioners. Call 0161 983 0902 weekdays.  Staff should share this with anyone they know who is bereaved.

Families bereaved by suicide should also be given the booklet ‘Help is at Hand’.

Key learning – Training all staff in suicide awareness

All frontline staff should be aware of how to support someone in distress.  At times staff may encounter people expressing suicidal thoughts.  Suicide awareness training may help them support clients, and signpost them to appropriate further support.  Stockport has a Suicide Prevention Training Matrix for all organisations to consider and make sure staff have received training appropriate for their role.

Suicide prevention awareness for professionals booking form – If you require any more information please email info@wellbeing@stockport.gov.uk

Learning Points

• Stockport Adult Social Care will promote the Team Around the Adult (TAA) model and are to review current guidance and develop outcomes to support embedding practice
• an increased understanding and awareness of assessment tools is necessary, when engaging with, and trying to empathically understand a vulnerable adult’s needs, in the context of child sexual abuse
• a GP masterclass in the Autumn was dedicated to promoting the familiarity and use of these in Primary Care. This was well received and is part of the ongoing offer of training in Suicide Prevention to Primary Care colleagues
• agencies acknowledged that when Jo’s dog became ill, it should have triggered a review of her risk assessment and risk management plan
• there was an over-reliance on the use of Jo’s personal email to maintain contact, which should not have been relied on
• PCFT has since set up a 24-hour phone-line for patients known to their service
• Stockport without Abuse will adapt their Trauma Informed Counselling offer to ensure that there is a more co-ordinated response with other agencies
• Guinness Housing have recognised the importance of how adverse child experience (ACEs) can impact on people in their adult lives and will include Trauma Informed Practice into their training programmes
• a weekly Mental Health Forum exists for the voluntary sector, where the group is used to share learning
• the Clinical Commissioning Group (CCG) Mental Health commissioning team is working closely with the police to support and pilot new ways of working
• there is a suicide awareness and response training package on the CCG virtual college system which has been circulated several times. GPs have also had some sessions on Masterclasses on suicide

Signposting for emotional and mental health support

All staff will want to be familiar with key sources of support and be able to signpost clients to them – both in the statutory as well as voluntary sector.  The Stockport leaflet ‘Are you feeling anxious, stressed, or low at this time? Helping you find the right support in Stockport‘ is a key signposting resource for all staff and residents.

Everyone in Stockport should know the Open Door 24/7 helpline (0800 138 7276), as well as the Open Door safe haven drop-in (72-74 Prince’s Street, SK1 1RJ) for Stockport residents in need of emotional and mental health support.

For suicide prevention in particular, the Greater Manchester ‘Shining a Light on Suicides’ website’ provides key resources, including:

a) help for anyone feeling suicidal

b) anyone concerned about someone else

c) anyone bereaved by suicide

We have produced and disseminated a comprehensive directory of mental health services.

Production of a paper and electronic ‘leaflet’ sharing the mental health offer, has been widely distributed across the partnership (to include pharmacies, shops etc.) with a ‘door to door’ leaflet drop in autumn 2020; and again with council tax bills earlier this year. Signposting of mental health services in the Emergency Department is to be put into place.

Safety Plans are a way to help someone plan steps to keep them safe from suicidal thoughts.  Staff can help someone make a Safety Plan and can ask whether someone already has a Safety Plan, to help guide their actions and responses.  You can find information on safety planning on the Staying Safe website, or learn more in the Suicide Awareness for Professional Course available to anyone working in Stockport.  The Stay Alive App also includes a safety plan and other resources. For example, safety contacts, reasons to stay alive, local services.

Next Steps – we ask that you:

1. circulate and discuss the issues of this briefing within your teams
2. attend the Stockport Safeguarding Adults Board (SAB) workshops in relation to the learning from this and other Learning Reviews
3. read and share the Executive summary
4. look at the recommendations made to the SAB – all partner agencies will implement the actions and report assurances back to the SAB on impact made from the learning.

Background

Tom was 63 years old who was diagnosed in 2018 with dementia. He lived alone with daily support from his brother including oversight of his medication and help in managing Tom’s finances. Tom would also attend the Wellspring daily for his lunch, he was always well groomed and smartly dressed in combat dress; possibly a legacy from, and his pride in serving his country during his previous career as a Royal Marine.

Incident

Tom was a long-standing tenant with Stockport Homes for over 20 years. Several team members were involved at various points, particularly during the last 5 years of his life, in providing support in relation to the management of the tenancy or claims for welfare benefits. 10 days before Tom’s death, safeguarding concerns were raised by his bank with Adult Social Care (ASC) and the police that Tom might be a victim of financial abuse by his brother who was taking Tom to the bank almost every day to withdraw large amounts of money from his account. An immediate police investigation concluded that there was no evidence of an offence having taken place. However, the police did have concerns about the brother’s financial arrangements and a safeguarding concern was made to ASC, who forwarded information to Pennine Care NHS Foundation Trust (PCFT) for an allocated social worker to visit Tom to assess his capacity around managing his finances, and explore whether his brother was a suitable person to be a carer for Tom and whether both were receiving the financial and care support they were entitle to. This referral was passed to the appropriate Community Mental Health Team (CMHT) for further enquiries to be made but Tom died before the planned visit could be made.

Cause of Death

An investigation was carried out by the police because the circumstances of Tom’s death were suspicious as he was found with significant injuries to his head and mouth. Following the review of all the evidence, which included further examination of issues relating to the management of Tom’s finances, the decision was made that no charges would be brought against the brother.

A post-mortem was initially unable to confirm the cause of death, this led to the pathologist identifying 3 main potential medical causes for Tom’s death:

• head injury
• epilepsy
• cardiac arrhythmia

The pathologist concluded that, on balance, the most likely medical cause of death was cardiac arrhythmia, also known as irregular heartbeat, where the heartbeat is too slow, or too fast. The head and facial injuries were believed to be historic.

Concerns

• Tom had been a potential victim of financial abuse. Initial concerns stemmed from the brother’s significant interest in Tom’s financial affairs and lack of response from Tom to attempts to contact him by Stockport Homes, and a subsequent text reply from his brother to say no further help was required
• Tom’s ability to manage and maintain his tenancy
• medication management and his inability to self-medicate
• lack of food in the house and Tom’s alcohol misuse
• Tom suffered with memory difficulties and was treated for Alzheimer’s disease given the family history
• Tom was considered to have capacity in relation to his support needs and finances, although no capacity assessment was conducted to support this rationale
• Tom’s brother was managing his finances due to his stage 3 dementia
• the building society made a referral to ASC to report their concern that the brother may be exploiting Tom financially
• was Tom’s brother working in his best interest? The building society’s understanding was that there was a power of attorney in place but that this had not been registered with them
• concerns had increased when both brothers went into the branch to withdraw £2000. Both brothers had been attending the bank daily, seeking to withdraw £500 for the purchase of a car. After 2 withdrawals of £500 had been made, further requests were declined because of concerns about Tom being vulnerable due to his dementia

Review process

It was originally anticipated that the review of this case would be carried out either as a Safeguarding Adults Review (SAR) or a Domestic Homicide Review (DHR) depending on the outcome of the police investigation. However, considering the outcome of the police investigation, it was agreed, after consultation with the Safeguarding Adult Board Independent Chair that the status of the review should be a Local Learning Review (LLR) which would be carried out using the standard SAR process.

Learning points

It’s important to record the rationale for concluding that a person has capacity in relation to the management of their financial affairs.

Most agencies identified learning, and included planned actions, to develop their staff skills in identifying possible indicators of abuse. The issues identified within the Individual Management Reviews (IMRS related to professionals: –

• not recognising the possibility of financial exploitation from the information supplied about the pooling of resources
• not showing professional curiosity to probe the information provided by brother about his intention to apply for powers of attorney or accepting at face value his assertion that he already had obtained power of attorney without asking for verification of this
• accepting at face value the assurances provided by Tom that he was happy with the financial arrangements, and not carrying out further visits to build a relationship and explore the situation further

Recommendations

1. Statutory partners will provide assurance to the SAB that findings and recommendations from the review are considered as part of the safeguarding procedures and processes review. The following will be considered:

• (i) The definition and use of multi-agency strategy discussions
• (ii) The process for providing feedback to referring agencies who raise safeguarding concerns
• (iii) The Team around the Adult (TAA) model
• (iv) The importance of keeping GPs and other health professionals informed of meetings  

2. Stockport Council working in collaboration with PCFT and NHS Stockport Clinical Commissioning Group, to review their joint guidance covering the arrangements for responding to safeguarding concerns.
3. Statutory partners should report to the SAB on steps taken to develop a multi-agency financial abuse toolkit which provides comprehensive guidance for professionals on best practice in identifying and investigating indications of possible financial abuse.
4. The SAB should bring to the attention of the Safer Stockport Partnership the findings from this review in respect of the identification and response to financial abuse, with a recommendation that consideration be given to approaching the Financial Conduct Authority (FCA) to explore the potential mutual benefits of supporting the FCA’s work on strengthening the national arrangements to protect vulnerable adults from the risk of financial abuse.
5. Partner agencies provide assurance to the SAB on actions taken to ensure agencies who are providing services to people with care and support needs, particularly those with dementia, have robust systems in place to:-

• ensure their records contain up to date contact details for family members and agree arrangements on who else should be notified of appointments.
• follow up any missed appointments, including exploration of any contributory factors which need to be considered when planning future contact.

Background

Ivy was 62 years old who had complex medical needs, she was morbidly obese and had recently been diagnosed with cancer. She lived at home and was visited by a care provider four times a day to assist Ivy with her needs, whilst Ivy had limited mobility and was bed bound.

Incident

In the 4months before her death Ivy was engaging with multiple agencies including Adult Social Care who were aiming to get her mobile and out of her house with the use of a wheelchair. Ambulance Services were responsible for transferring Ivy to and from hospital appointments with the aid of a bariatric ambulance to ensure her safety, dignity and comfort. Ivy also had a commissioned package of care consisting of four calls per day.

In April 2019, Ivy’s GP attended her home following concerns raised by her care provider. An ambulance delivered Ivy to hospital where she was assessed in the Emergency Department but not formally admitted to the hospital. If Ivy had of been formally admitted into hospital, then the expectation would be for the hospital to activate the standard discharge protocols.

Whilst Ivy was in ED, she was placed in a side ward where she was being cared for by hospital staff until a suitable vehicle was available to take her home. During this time, Ivy is recorded to have contacted her care provider to inform them she was returning home. However, there was no mental capacity information recorded for Ivy at this time, and it cannot be substantiated if this happened.

A suitable ambulance had become available, Ivy was returned home to bed, she was not seen by her care provider, friends or family until 13 days later, when she was being collected by her ambulance crew to attend an outpatient’s hospital appointment. Ivy died several days later in hospital.

Cause of Death

Ivy’s causes of death was identified as a combination of Sepsis, Pneumonia, Pyelonephritis (kidney inflammation due to bacteria), limb ischaemia (sudden lack of blood flow to a limb), pressure ulcers and epithelial damage due to prolonged contact with urine, Obesity and type II diabetes. These conditions reached a deadly status because she was stranded in her bed without care. Ivy’s single call during the 13 days unattended was made to Ivy by a nurse to discuss her diabetes. She did not answer the phone and the GP’s records from this time show Ivy was incorrectly labelled as ‘admitted’ to hospital.
The conditions that caused Ivy’s death can to some extent be attributed to inadequate communication between agencies, and some were triggered by inadequate care.

Communication

Ivy’s care provider suspended her care package in the belief that she had been admitted to hospital. In fact, Ivy was ‘assessed’ but not ‘admitted’ to the hospital. It has become clear that this terminology can be interpreted ambiguously, and that further work is required between agencies to ensure a clear understanding of terminology and language is used across all agencies.

Adult Social Care contracts with care providers contains a general expectation that the care agency will keep in touch with clients who are admitted to hospital. Ivy’s claim to the hospital staff that she had spoken to the provider by phone should not be considered adequate assurance. As such this expectation was not met in Ivy’s case.

Transferring of care

Ivy’s circumstances fell outside normal hospital discharge procedures as she was not actually admitted to hospital. Both hospital and ambulance staff were assured by Ivy that her care was in place when in fact it had been cancelled. This was not challenged or checked as Ivy was believed to have the capacity to make her own decisions and express her wishes and feelings. Conversations between professionals and service users, should be recorded, when discussions take place on how an individual’s care and support needs will be met upon their return home. This includes, what outcomes have been discussed and agreed, and what actions professionals will take to notify care providers or other agencies.

Repeated incident

There had been a previous incident that had happened to Ivy in 2017. After a hospital admission, a different care provider was not informed that Ivy had been discharged. She was again left in a soiled bed, unfed for 24 hours. Learning was not embedded in to practice sufficiently.

Learning points

1. a decision to suspend a care package for an adult at risk must be made on facts not assumptions
2. all parties to a contract [including the third-party client] can benefit from agreed specific expectations in the contract
3. clear policy can empower staff to ensure that risks are managed appropriately for clients who attend the Emergency department who are known to have care and support needs within the context of the Care Act 2014
4. the periods of transference of both care and responsibility between agencies are high risk
5. failure to investigate and record the outcomes of high-risk incidents means that the risks remain and can recur.

Next steps:

1. circulate and discuss the issues of this briefing within your team
2. review your personal and collective practice in the areas identified
3. attend the workshops that SSAB will be delivering in relation to the learning from this and other Learning Reviews
4. find the Full Overview Report (PDF 345Kb)
5. look at the recommendations to the SAB – all partner agencies will progress actions and present assurances to the SAB on impact made from the learning

Background

JN was a Manchester resident who died in 2019 due to ketoacidosis, alcohol related liver disease and cardio myopathy. Although JN’s case did not meet the SAR criteria, questions raised by the family prompted a learning review which provided valuable insights.

Context and initial treatment

JN was a corporate professional, mother and wife who had historically been a perpetrator in several domestic abuse incidents and had served a short prison sentence for drunk driving. Whilst on holiday in 2015, JN became ill and injured to the extent that her mobility was severely reduced. JN’s relationship with her husband became dysfunctional so a decision was made for her to move out of the family home to private accommodation. She subsequently became reliant on benefits and began to misuse alcohol which resulted in accidents in the home. JN also reported being threatened by her husband’s family to the police.

JN was offered a range of services to support her needs, including those offered by Adult Social Care (ASC), TPA and Psychological Medicines. Collectively these should have allowed her to continue to live independently. JN was deemed to have capacity, and the ability to make her own choices on how she led her life.

Further treatment

In March 2019 JN was scheduled to attend a 2-week detox session. After instances of JN claiming to not feel well enough to attend or over-sleeping, JN finally attended and completed the course. However, this set a precedent for further nonengagement from JN with services. JN chose not to complete her detox after-care plan and claimed she felt well enough to continue on her own. Her case was closed to the TPA, but by June, JN had started drinking excessive amounts of alcohol again. JN’s GP denied a request from her for a prescription of sedatives due to it being potentially dangerous. Apart from this, JN continued to not engage with services or attend appointments. Most of the contact between JN and services was made by phone. In mid-August 2019, JN told a pathfinder keyworker that there was blood in both her vomit and stool. She was told to seek medical assistance. This was the last professional contact JN received before passing away. Given JN’s known non-engagement in services it would have been reasonable to have reported JN’s relapse into significant alcohol consumption and ill health as a safeguarding concern, but this did not happen.

Communication and documentation process

A number of agencies were involved in providing support to JN and there were examples of good practice by all as well as inter-agency working to engage with JN. However, there was little overall coordination, which resulted in some agencies not being aware of the role of others in supporting her. JN reported to ASC she was having suicidal thoughts. JN’s GP did subsequently make contact to address this issue, but JN declined the appointment as it conflicted with her detox session. As part of the learning review, some health professionals felt concern over sharing information on JN with other agencies if there was no legal requirement. It was also noted that most of the professionals involved with JN were reliant on communicating with her on the phone, rather than making physical visits which may have provided more information in to her wellbeing or actively encouraged participation in services. Although several agencies deemed JN to have capacity and have awareness of the risks of her lifestyle choices, this was rarely formally documented. The above is indicative of some of agencies ‘working in isolation’ and not sharing information when working with JN.

Findings – working in isolation

The learning review raised concerns on the lack of effective case coordination. For example, colleagues from Psychological Medicines and the TPA were not aware of each other’s involvement with JN until the review. Furthermore, both the TPA keyworker and social worker closed JN’s cases around the same time without consulting each other. The learning review found that although both decisions were justified within the remit of their organisations, if they had consulted each other a different decision may have been made regarding withdrawing their service engagement. The review also found that the Adult Social Care worker did not raise the closing of JN’s case during supervision sessions and as such the decision was not subject to management approval or peer review. Throughout this period the Direct Payment team at ASC had oversight of JN, but JN would not engage with them despite repeated attempts.

Further findings

The participants at the learning review felt that, in retrospect, the formation of a Team Around the Adult may have proven beneficial in creating clearer communication and cooperation between agencies, as well as identified self-neglect. JN was adamant that she did not want the situation discussed with her husband, however participants felt more effort could have been made to employ JN’s friends in the cause. Concern was also raised that no agency escalated JN’s lack of engagement until just before her death.

Learning points

• Team around the Adult processes and the VIP Front Door project frequently improve outcomes for individuals and should have been considered
• there should have been better documentation around capacity and JN’s understanding of the risks associated with her behaviours
• guidance for non-medical professionals on the actions that they should take in relation to suicidal ideation would be helpful in promoting consistent access to services
• where there is a history of non-engagement, professionals should be alert to the potential for the escalation of untreated illnesses. The identification of supportive friends or family can be helpful in engaging with reluctant clients
• mandatory management oversight of case closure in Adult Social Care can ensure that clients who choose not to engage are supported in the best way possible for an appropriate time period
• the observation of a period of stability and consultation with other agencies prior to the closure of a case is likely to lead to better client outcomes
• effective case coordination and the enhanced ability to escalate where necessary is likely to ensure that a client has the best outcome possible and provides opportunities for professionals to work together in a co-ordinated approach

Background

63 year old Martin was a resident of a care setting with complex medical issues. He passed away as a result of an injury sustained when falling from a recliner on 6 August 2018.

Context and initial treatment

Martin had been a resident in the care setting for 18 years. He had a complex medical history including diabetes, peripheral vascular disease resulting in bilateral below knee amputations, morbid obesity and schizophrenia resistant to treatment. Martin’s only next of kin was his elderly father.

On 7 June 2018 Martin sustained a shearing injury to his sacrum, likely after falling from his recliner chair. He would not comply with wound care from staff and claimed to be following instructions from the voice of ‘Jovah’, a symptom of his illness. Following 2 conflicting capacity statements from 2 separate GPs, it was noted that Martin had fluctuating capacity and 11 days after the injury saw the Tissue Viability Nurse (TVN) for the first time. The wound had become malodorous.

Further treatment

Over the next 10 days, Martin was assessed and treated by multiple care staff. The wound became infected. A Best Interest Meeting (BIM) was held with a 3rd GP, Community Psychiatrist Nurse and Martin himself. However, the TVN, surgical team and father were not present. Furthermore, an Independent Mental Capacity Advocate (IMCA) was neither involved or considered. Several key communications relating to treatment were sent by fax rather than email, potentially delaying information dissemination. It was agreed to be in Martin’s best interest that he undergo debridement (the removal of damaged tissue or foreign objects from a wound).

Communication and documentation process

Following the BIM, Martin was subject to 5sessions of debridement, with the wound steadily deteriorating. In each session there was consistently no formally documented capacity assessment. In each session, no IMCA was sought despite initial raised concerns. Frequently, the TVN was not informed of Martin being admitted to hospital and staff from the care setting were not provided with information on how to treat Martin postdischarge. In one debridement session, Martin claimed to experience pain which was not responded to by the staff performing the treatment.

Findings

The Single Agency Health Review states that agencies did consider how Martin’s mental health impacted his capacity to make decisions about his care, but these were not formally documented by either GPs or within hospital records. Furthermore, no valid consent process seems to have taken place, however the TVN has provided good evidence of involving Martin in decisions. The lack of Independent Advocates was sub-optimal and little consideration of Martin’s comfort was made during debridement, even after challenges from a carer from Martin’s care setting.

Further findings

The TVN suggested conducting osteomyelitis investigations which were not actioned. Multiple agencies believe there was a lack of ownership of Martin’s care. Whilst much communication between agencies was of a high standard, there are ample examples of it being unsatisfactory.

Learning points

• capacity assessments should be thorough and undertaken in context of and individual’s changing mental health
• when an individual lacks capacity, IMCAs should be involved, best interest discussions should happen and be properly documented
• NHS Foundation Trust consent policies need reviewing
• communication and referral pathways between health services should be reviewed, with fax no longer being a suitable medium
• onward urgent referral to another surgical speciality should be performed by someone familiar to the patient
• detailed discharge planning should take place regarding equipment, medication and dressings to assist carers outside a hospital setting
• NHS Foundation Trust should promote continuity of care
• consider analgesia for debridement sessions and ensure analgesia is available when dealing in pain management
• since the learning review, practice has been reflected on, and both NHS Foundation Trust and GPs are working collaboratively to work within the recommendations