Tyrone was a 24 year old man who committed suicide in February 2019.
The review examines the circumstances and issues leading up to Tyrone’s death, including homelessness (amid the ‘housing crisis’), mental ill-health and suicide prevention, all linked to Autism Spectrum Condition and learning difficulties.
We would strongly encourage all professionals to read the attached 7 Minute Briefing and the full report for this important review which can be accessed here:
Hampshire Safeguarding Adults Board
Learning Summary following the Mr C SAR and the Thematic Review of Learning from SARs related to Learning Disability and Physical Health Care
Background
The Hampshire Safeguarding Adults Board undertook a Safeguarding Adult Review regarding Mr C. Mr C had complex care and support needs and was being supported by a number of agencies. Mr C experienced a series of placement moves which had an impact on his emotional wellbeing resulting in a deterioration of behaviour. He stopped eating and drinking which led to a decline in his physical health. Concerns were expressed by Mr C’s care team that there may be an underlying physical cause for him not eating and drinking and losing weight. He was admitted to the local acute hospital trust for observations and diagnostic tests. Mr C was discharged 7 weeks later as it was felt that his condition was due to behavioural and not physical causes. Mr C was discharged to a nursing home in a poor physical state where he received end of life care and he died four days later.
Following Mr C’s death, concerns were raised about his care whilst in hospital, specifically that during his admission, he had not received the necessary tests to rule out a physical health condition as a root cause of his physical presentation. There were also concerns that he was transferred to a nursing home apparently at the end of life when this was not known to those that were receiving him into their care or the community learning disability team.
In addition to the Mr C SAR, the Hampshire Safeguarding Adults Board simultaneously commissioned a thematic review to examine this case alongside two previous SARs carried out under similar circumstances – Mr A (June 2013) and Ms B (Dec 2015). In all three cases, the adults had a learning disability and there were concerns about how their deteriorating physical health was managed. In each case, the death had been premature and unexpected. This raised questions about the effectiveness and embedding of the learning from the previous two SARs and so HSAB undertook a thematic review to identify progress in implementing learning from the previous cases. The Thematic Review also provided an opportunity to explore the blocks and barriers to embedding of learning and solutions to these.
Common issues identified across all three cases include:
The learning from both the Mr C SAR and the Thematic Review is outlined below. HSAB has produced a multi-agency action plan designed to drive the improvements identified in the review recommendations:
1. Understanding and application of the Mental Capacity Act 2005 (MCA)
All local agencies to:
2. Communication and coordination
Health partners to:
3. Hospital passport
Health partners to:
4. Discharge Planning
Health partners to:
5. Transition
Local partners, led by Adults Health and Care to:
6. Escalation and challenge
Miss T
Buckinghamshire Safeguarding Adults Board commissioned an Independent Safeguarding Adults Review (SAR) following the death of Miss T, who was aged 34, living alone in Buckinghamshire. It would appear from agency records that she was last seen in the November 2015 and found dead in an advanced state of decomposition some three months later. The case of death could not be established.
It is clear from this case that although there was clear evidence of good practice from certain agencies, such as Thames Valley Police and her general practitioner there were also areas where practitioners could have communicated more effectively. It also highlighted the difficulty of respecting an individual’s right to a private life at the same time as trying to keep them safe from harm, in this case self-neglect.
Mr Q
Buckinghamshire Safeguarding Adults Board commissioned an independent Safeguarding Adults Review (SAR) following the death of Mr Q who was aged 74, who had a long standing history of mental and physical health needs. At the time of his death he had just been discharged from a stay in hospital and was being supported at home by carers. The coroner recorded that he died from bronchopneumonia and associated severe kyphosis which was secondary to ankylosing spondylitis.
It is clear from this case that although there was clear evidence of good practice from the care agencies and his general practitioner, that there were issues regarding communication between agencies and the lack of identification of the vital role played by his informal carer.
The Brighton & Hove Safeguarding Adults Board commissioned a Safeguarding Adults Review (SAR), following the death of ‘X’ who was aged 59 years and rough sleeping in the city. The Coroner recorded a verdict of ‘misadventure to which self-neglect contributed’.
There are two important recommendations to share with the network:
The full report and briefing for staff can be read here:
X Safeguarding Adult Review April 2017
Staff Briefing X SAR
Ms F was a young woman who died of sepsis. With the exception of her GP, her case was not open to any service until just before her death, when she was referred to Adult Social Care by the Police. Other members of the household were well known to many services in Reading including Antisocial Behaviour and the Police, both as victims and perpetrators.
Details here:
Mr I had suffered a brain injury and had a lower leg amputation. He was prone to depression and developed an increasingly severe dependence on alcohol. He resented contact from the services and was aggressive to visitors including the regular care staff who had been commissioned by the Local Authority to provide daily support and monitoring. His case was transferred from the Local Authority Long Term Team (LTT) to the Mental Health Review and Reablement (R&R) Team in June 2013, but despite their best efforts the new keyworkers struggled to develop a working relationship with him. Mr I was assessed as having the mental capacity to make decisions about his health and welfare. The keyworkers took his case to the Risk Enablement Panel (REP) in April 2014 hoping that the case would be transferred, however the REP instead encouraged them to continue with their attempts to engage Mr I. However no meaningful work was possible due to Mr I’s use of alcohol and reluctance to engage, and so it proved very difficult to reduce the risks involved.
The daily carers continued to call but often did not manage to see Mr I, so the police would occasionally be asked to undertake welfare checks. In July 2014 it was agreed by the workers and managers of both teams that the case should be transferred back to the LTT and held on duty (as opposed to being allocated), however due to other work pressures the mental health keyworker did not progress the transfer. In April 2015 the keyworker took the case back to the REP who agreed that the decision to transfer the case back to the LTT should be progressed. However the usual procedures for handover recording and case transfer on the health and the Local Authority IT systems were not completed correctly by the R&R team.
At this time a significant re-structure of the Local Authority teams resulted in the LTT duty function being provided by the Single Point of Access (SPOA) team. A period of confusion and increasing frustration between teams followed. The case began to be managed by the SPOA but they had no access to the recent mental health records and the transfer had not been formally confirmed. This led to a lack of clear accountability for the case. During this period the teams were unaware that Mr I’s physical health was significantly deteriorating. He died unexpectedly in June 2015 and was found in his home several days later by the police.
Details here:
In February 2016, the Board received the Serious Case Review of young woman with learning disabilities thought to have been the victim of domestic violence and sexual exploitation. A Practitioner Briefing Sheet has been produced by the SSAB’s Learning & Improvement Subgroup, outlining the key themes and findings to emerge from the review. Decision taken not to publish this report, as Ms C and children are all alive, being actively worked with and despite attempts at anonymity, detail within report would be too recognisable
More details here:
In June 2016, the Board received the Serious Case Review concerning a man who, in his early twenties, sustained a traumatic brain injury in a road traffic accident. Tom took his own life in 2014, aged 43. A Practice Briefing Sheet has been produced by the SSAB together with the author of the review, outlining the key themes and findings to emerge from the review. The full review will be published following completion of a Coroner’s enquiry later in 2016.
More details here:
Mr. AA was a Norfolk resident, aged 42 years. He was diagnosed as living with paranoid schizophrenia and had received mental health services over a long period of time. At the beginning of 2014 he went into a period of decline and died in a Suffolk hospital in January 2014. The cause of death was bronchopneumonia but concerns were raised about the intervention he received up until the time of his death. As a result a SAR was commissioned, in partnership with Suffolk SAB.
More details here:
Ms B was a 46 year old woman who had a mild learning disability, personality disorder and epilepsy. She was a Portsmouth City Council client who lived in a residential home in Hampshire. She was born on 05/03/68 and died on 12/09/14 at Queen Alexandra Hospital. In this case Ms B’s care and support in the last weeks of her life had involved a complex mix of physical and mental health and care services. Her behaviour had changed significantly and different approaches to respond to this were attempted, but with limited success. Finally her physical health required her admission to hospital and was found to have deteriorated so substantially that little effective treatment was possible. This sequence of events was thought to bring Ms B’s case within the requirements of s44 of the Care Act 2014 as it was appropriate to examine more closely how well the partner agencies and systems in place had worked in responding to Ms B’s needs
Ms B Safeguarding Adult Review Report December 2015
Ms B Safeguarding Adult Review Executive Summary (December 2015)
CS, an 18-year-old young man, was found submerged in the bath at his residential unit on 4 July 2013. Staff administered CPR and he was transferred by ambulance to hospital accident and emergency department but sadly died later the same day. He had Klinefelter syndrome and experienced learning disabilities, autistic traits and epilepsy and tonic clonic, partial and absence seizures.
CS was admitted to a specialist unit on 19 March 2013. This is a seven-bed in-patient facility for adults with learning disabilities, mental health problems and/or challenging behaviour. At the time of admission, CS was under medication for his epilepsy and his care plan said he should be checked every 15 minutes during baths to ensure he was ok. On the morning of 4 July CS was found submerged in the bath. He sadly died later the same day. Southern Health Foundation Trust commissioned an independent review in November 2013 into the care and treatment provided to CS up until his death. A summary of the professional learning is summarised below:
Professional Learning
On 20th April 2011 Alice was being accompanied by Mencap staff to attend church when she fell. The Mencap staff called an ambulance and, despite some initial discussions about whether to take Alice home, the ambulance crew took her to hospital for assessment. Alice was admitted to Northampton General Hospital on 20th April 2011, where she died on 26th May 2011. Alice was 54 when she died. Serious concerns were raised about the care and attention Alice received from both East Midlands Ambulance Service and Northampton General Hospital in the time between her fall and her death. Northamptonshire County Council received three safeguarding alerts regarding Alice’s care while Alice was in hospital. Northampton General Hospital undertook a serious incident investigation and the findings from this and from the safeguarding investigation were considered by an Adult Safeguarding Case Conference on 27th July 2011. EMAS also undertook a serious incident investigation and the case conference found neglect in respect of both East Midlands Ambulance Service and Northampton General Hospital. The circumstances of Alice’s care were escalated to the Northamptonshire Safeguarding of Vulnerable Adults Board, who decided that a serious case review should be undertaken. This decision was taken to better understand the reasons behind a failure to meet Alice’s care and clinical needs and to learn lessons to improve services going forward.
Professional Learning:
These are the same themes that run through the plethora of research documents and inquiries into the health care of people with learning disabilities that have been published over recent years. While it is recognised that these publications have largely been in respect of the ongoing health care needs of people with a learning disability and access to services, it is suggested that the findings could also be applied to emergency interventions. There is resonance with Alice’s experience in particular findings of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD), March 2013 which are summarised as follows:
The report of the Serious Case Review into Orchid View has been published. The review was launched last October after an inquest found that neglect at the West Sussex home had contributed to the deaths of five residents and that a further 14 had received ‘sub-optimal’ care. The report makes more than 30 recommendations.
Professional Learning:
In 2013 the Somerset Safeguarding Children Board and Somerset Safeguarding Adults Board commissioned research to explore the circumstances surrounding the lives of 13 young people who all had been, at some point in their lives, in care in Somerset but sadly died prematurely. The research aimed to learn more about how services can best support care leavers in their transition to independent adulthood in order to better shape the future organisation and delivery of services to this vulnerable group. Monitoring and improving transitions between and across services remain a priority for the SSAB.
Somerset Learning Review June 2014
Southern Cross Health Care operated at St Michael’s View with a culture that had no effective measures in place to prevent abuse and neglect. There was a lack of clear governance, direction and oversight from managers, nursing and care staff. There was lack of effective workable policies and procedures. In addition there appeared to be a lack of awareness of whistle blowing procedures or any effective safeguarding training to support staff to raise appropriate concerns in line with their safeguarding responsibilities. Therefore the voice of the resident was not apparent.
Professional learning:
2013 December SCR regarding St Michael’s View (South Tyneside)
Mr A had a learning disability and was 52 years old when he died at the Queen Alexander Hospital, part of Portsmouth Hospitals Trust (PHT) on 31st May 2010. Many agencies had been involved in Mr A’s care prior to his death and it was considered that an SCR would be the best approach in which to capture learning on a single and multi-agency basis.
Professional learning:
Mr J was a fifty-nine year old vulnerable adult living in supported temporary housing after a period of homelessness following the breakdown of his marriage. In May 2008 he saw his GP and reported that his memory had deteriorated dramatically and that he used to have an alcohol problem. He was referred to mental health services where it was found that he had Alzheimer’s disease. Mr J was treated with medication and monitored. It emerged during 2008 that Mr J was experiencing difficulties with other residents at the supported housing and their associates. These people were variously said to be prostitutes and drug users. There were reports of thefts from Mr J which were investigated by police. Mr J would not agree to criminal charges being brought. It was judged that Mr J was able to live more independently and he moved on from the temporary accommodation he was in and he moved to alternative accommodation. In early 2009 police became aware of concerns he was still being exploited by acquaintances he had met at his previous accommodation. Police were involved in criminal investigations when Mr J made allegations against these people but he subsequently withdrew the allegations or they could not be substantiated. He was seen twice in the Accident & Emergency Department with facial injuries, which he insisted had been caused accidentally. Mr J was subject to a safeguarding referral which resulted in him moving to a care home on a temporary basis as a place of safety. After a short period, Mr J moved back to his own home. Monitoring visits found Mr J not be coping well. There were indications of excessive drinking, disorientation and inability to manage personal care needs. Two weeks after returning home, Mr J was taken to hospital where he was found to have multiple cuts, bruises and possible pressure sores of varying ages, and to be extremely dehydrated. He had multiple injuries to his brain. He deteriorated further and died in hospital four days later.
Professional learning:
Mrs Foster was left alone for nine days without her essential privately funded care and support service when the provider company ceased trading. She died eleven days after being discovered by a visiting district nurse and her admission to hospital. Police investigations concluded the action or lack of action of any person did not meet the criminal threshold of wilful neglect or ill treatment. The actions involved, or rather inaction, were not intentional or deliberate. Nor can the employing council be shown, at senior manager level, to have criminally breached their duty of care. The SCR found that Mrs Foster would have benefited from better multi-agency care coordination and review from August 2009. Besides offering a potential improvement to the quality of her life this may have avoided her falling victim to events. The provider failure protocol subsequently put in place by Surrey addresses the necessity to treat service closure as a significant occurrence demanding of focussed leadership. It includes, for example, the use of timed handover logs and scheduled debriefings that would have picked up the omissions that left Mrs Foster without home care for nine days.
Professional learning:
2013 September Serious Case Review regarding Gloria Foster (Surrey)
Mrs D died following an accident and a brief period of treatment in hospital and the community. The injury which Mrs D sustained falling from her wheelchair in the summer of 2011, resulted in a period of hospitalisation and a decision to treat her neck injury using a supporting neck collar. The collar itself caused friction to her skin resulting in the formation of a pressure ulcer. This ulcer in turn eventually became infected and Mrs D died as a result of the septicaemia, or infection based blood poisoning which it caused. Mrs D was an elderly woman with a number of disabilities and health concerns prior to the incident which ultimately led to her death. She was extensively supported by her family. This serious case review examines the underlying causes of Mrs D’s death and provides recommendations to reduce the likelihood of their recurrence in the future.
Professional learning:
Slingshot