SAFEGUARDING ADULT REVIEW USING THESIGNIFICANT INCIDENT LEARNING PROCESS

OF THE CIRCUMSTANCES CONCERNING

ADULT A

Author: KAREN REES

March 2018

This report is strictly confidential and must not be disclosed to third parties without discussion and agreement with the WSAB.

The disclosure of information (beyond that which is agreed) will be considered as a breach of the subject’s confidentiality and a breach of the confidentiality of the agencies

involved.

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Contents

1. Introduction and Scope of Review 3

2. Significant Incident Learning Process 3

3. Family Involvement 4

4. Parallel Processes 4

5. Background 5

6. Key Episodes 5

7. Analysis by theme 9

8. Good Practice 25

9. Conclusions and Lessons Learned 25

10.Recommendations 27

Appendix One: Terms of Reference (Redacted) 28

Appendix Two: Swiss Cheese Model; Anatomy of an Error 31

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1. INTRODUCTION AND SCOPE OF REVIEW

1.1. Adult A was an 84-year-old who was admitted to hospital in December 2015 after having been found on the floor of her flat by the attending paramedics. There were concerns raised by the paramedics about the state of the flat indicating possible self-neglect and neglect by carers. Adult A also told the paramedics that there was money missing. The paramedics raised a safeguarding alert related to these concerns.

1.2. Adult A was admitted to an intermediate care bed1 and then discharged back home.

1.3. In mid-January Adult A activated her care line, the paramedics who attended reported that she was found in a situation of serious self-neglect sitting in a cold dark flat and was severely hypothermic. There was no fresh food in the flat and it appeared that Adult A had not been talking her medication.

1.4. Adult A died in hospital the following day. The coroner noted that at the time of death, Adult A was suffering from hypothermia, broncho-pneumonia, left ventricular hypertrophy, hypertension, diabetes, kidney disease and dementia.

1.5. The coroner concluded that Adult A would not have died at that time had she not been discharged home. The coroner issued Regulation 28 Reports2 to prevent future deaths for several organisations. On receipt of these letters, senior executives from those organisations responded to the coroner indicating that they had referred the case to the Wiltshire Safeguarding Adult Board (WSAB) to consider whether the criteria were met for a Safeguarding Adult Review (SAR).

2. THE SIGNIFICANT INCIDENT LEARNING PROCESS (SILP)2.1. The Care Act 2014 Statutory Guidance states that the process for undertaking SARs

should be determined locally according to the specific circumstances of individual cases.

2.2. WSAB agreed the criteria were met to undertake this review and to use the Significant Incident Learning Process (SILP), a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted in a certain way at the time.

2.3. The SILP model of review adheres to the principles of:

Proportionality  Learning from good practice  The active engagement of practitioners involved at the time Engaging with families Systems methodology Avoidance of hindsight bias

 This SAR has been undertaken in a way that adheres to these principles.

The Lead Reviewers

1 An intermediate care bed is used to bridge the gap between hospital and home and can offer further assessment and rehabilitation to identify needs and support a person back to independent living at home. 2 Reports to Prevent Future Deaths. Paragraph 7 of Schedule 5, Coroners and Justice Act 2009, provides coroners with the duty to make reports to a person, organization, local authority or government department or agency where the coroner believes that action should be taken to prevent future deaths. http://www.legislation.gov.uk/uksi/2013/1629/part/7/made accessed 26 January 2018

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2.4. Karen Rees is from a nursing background, having worked for 36 years in the NHS. Latterly Karen worked in safeguarding roles at a strategic level in two NHS organisations. Karen has worked with both Safeguarding Adult and Safeguarding Children Boards over a number of years and specifically on Serious Cases and Case Review sub groups. The review was chaired by Donna Ohdedar. Donna Ohdedar is a solicitor with a public law background as Head of Law for a metropolitan authority who is an experienced chair and author of safeguarding reviews. The lead reviewers are entirely independent of WSAB and its partner agencies.

Process

2.5. Following the decision by WSAB to commission a SAR, a scoping meeting and authors’ briefing took place in September 2017 to agree the Terms of Reference with representatives from WSAB and to introduce the SILP model process and expectations to authors of agency reports.

2.6. All agency reports were completed within the timescale and a Learning Event took place on 7th December 2017 which was attended by authors, managers, some practitioners and safeguarding leads from the organisations involved in Adult A’s care. Further agencies involved were identified; reports were requested from these agencies in time for the Recall Event.

2.7. A Recall Event took place on 25th January 2018 prior to which the first draft of the report was circulated for comment. The Recall Event tested out the learning and gave opportunity for participants to give their perspectives.

2.8. It is of note that not all agencies were able to engage at the learning and/or recall events. Most agencies did not send frontline practitioners involved in the case despite clear briefings and reminders about the reasons for this requirement.

2.9. The final report was presented to WSAB on 28th March 2018.

2.10. It is the expectation that this review will be published in line with Care Act (2014) requirements.

3. FAMILY INVOLVEMENT WITH THE REVIEW

3.1. The lead reviewers contacted a relative of Adult A who was a nephew by marriage. He provided some detail of history and observations of the care provided and raised some issues. His thoughts and comments have been included within the report. He was keen to be involved with the review and wanted to be provided with feedback on the findings and recommendations at the end of the process.

4. PARALLEL PROCEEDINGS

4.1. There were no criminal proceedings as a result of the death of Adult A.

4.2. The coroner’s inquest was completed in May 2017 and recorded a narrative conclusion.

4.3. The coroner stated that the following contributed to her death:

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The failure to identify the cognitive impairment before discharge. Poor communication between some members of the Multi-Disciplinary Team

and other specialists and individuals and organizations involved and the poor use and application of external advice and a failure to ensure continuity of care at home.

Inadequate training relative to issues arising in respect of people lacking capacity in the community and the ability to apply for safeguarding measures.

5. ADULT A BACKGROUND

5.1. There is very little known about Adult A in professional records. It is recorded that she worked at an air base from the age of 14, married and was widowed several years prior to her becoming known to professionals; she had no children. Adult A appeared to be a fairly isolated person but did have a sister and extended family living some distance away. Adult A lived alone in a first-floor housing association flat accessed by 15 concrete stairs. Adult A’s sister indicated to professionals that there was a longstanding history of poor engagement with offers of care, support and treatment. This behaviour is evidenced within the GP record.

5.2. Adult A’s nephew informed the reviewers that, after the death of her husband, she had stayed with her sister two or three times a year and every Christmas, often staying at the home of the nephew. There was also weekly telephone contact to check that Adult A was well and whether she needed anything.

5.3. The GP who was aligned to the Care Home identified that Adult A had diagnoses of type 2 diabetes, osteoarthritis, falls, leg ulcers and hypertension.

6. KEY EPISODES

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Key Episode One: Pre-Scoping Period (Pre 20/12/2015)

6.1. In order to understand the circumstances immediately leading up to Adult A’s admission to hospital, it is relevant to identify key information and what professionals understood about Adult A prior to her fall and subsequent admission.

6.2. Adult A was seen by the Community Nurses from the Community NHS Trust intermittently between 2009 and 2015 to manage and dress leg ulcers.

6.3. Adult Social Care assessed Adult A’s care needs on several occasions between October 2009 and October 2014. These assessments were undertaken as a result of referrals received from professionals (the Primary Care Coordinator3 made four referrals in this period) and also from Adult A herself. Following assessment, care to Adult A was funded by the local authority initially.

6.4. In July 2012, a Customer Coordinator4 in Adult Social Care undertook an assessment of care and support and a resource specialist5 advised that a low-level package of support was needed. The amount of care to be provided was under the threshold for social care funding. At this point, Adult A was identified as having Mental Capacity6 and would be self-funding.

6.5. In April and October 2013 and on 9th December 2015, Adult A activated the Care Line following falls and the ambulance services attended.

6.6. In 2014, Adult A was offered investigation and treatment for ongoing knee pain that was reducing her mobility via the GP, Interventions were declined by Adult A.

6.7. It is of note that the professionals identified above, that had contact with Adult A in this episode, and specifically in earlier December 2015, did not raise any concerns regarding issues of self-neglect. The housing association who Adult A rented her flat from, indicated no concerns were reported related to her tenancy.

Key Episode 2: First Admission to Hospital

6.8. On 20th December, an ambulance was called by a neighbour of Adult A. The Police were called to force entry so that the paramedics could attend to Adult A.

3 Care coordinators work within GP practices and may be clinicians or non-clinicians as a support to individuals. They do not offer services directly but can work for example with self-funding patients who may have limited services to support them. 4 Customer Coordinators are not qualified social workers and are able to assess lower level needs of customers.5 A resource specialist is not a qualified social worker and will assess what resources are required at the time of the assessment6 Assessment of Mental Capacity is required under the Mental Capacity Act (2005) if there is concern that a person lacks the capacity to make a specific decision about care and treatment or other decision due to a disturbance or impairment in the functioning of the brain. https://www.legislation.gov.uk/ukpga/2005/9/contents

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6.9. The paramedics found Adult A on the floor and did not find any injuries. There were concerns about Adult A’s chronic health needs, the unhygienic home conditions and evidence of faecal staining around the flat. Police attending concurred with the view of the paramedics related to the unhygienic conditions, but noted that the paramedics were taking an appropriate lead on the call out. There was also little food evident, raising concerns about how Adult A was eating and managing her diabetes. The paramedic contacted the out of hours GP service. It was decided that although there were no immediate medical concerns, the social and living circumstances were of enough concern to indicate that it was not safe for Adult A to stay at home.

6.10. The GP identified that Adult A should be referred to the Access to Care service for admission into an intermediate care bed7. A bed was found at the Care Home but would not be available until the following day. It was therefore agreed that Adult A would be conveyed to the Acute Hospital as a place of safety.

6.11. The ambulance crew, reported the safeguarding issues to the clinical desk within the ambulance control centre so that a referral could be sent to adult social care. The referral included three concerns:

self-neglect. carer neglect as there was a care plan in the flat but the paramedic did not

think that any care was being delivered. Financial abuse as Adult A alleged money was missing.

6.12. The paramedics undertook a 6CIT8 test, scoring 16 out of 28 and deemed that Adult A had reduced capacity.

6.13. The Acute Hospital indicated that there was no indication that Adult A did not have capacity to make decisions about her care and therefore no formal assessment of mental capacity was undertaken. The emergency department were aware of the 6CIT score related to cognitive function.

6.14. Adult A’s assessments indicated that she was self-caring other than being assisted to wash. She was not dehydrated and there was no indication that she did not eat or drink during her stay.

6.15. An agency nurse from within the emergency department made a safeguarding referral based on the information from paramedics and presentation on arrival. This was not received by Adult Social Care.

6.16. The safeguarding referral from the paramedics was received by the Emergency Duty Service in Adult Social Care. Details related to the financial abuse were not evident in the referral. As Adult A was now in hospital, any issues of self-neglect were deemed to be addressed during her stay in intermediate care. The referral was passed to a social work team for a care and support assessment (as opposed to the Adult Safeguarding Team for a safeguarding investigation).

7 Intermediate Care Beds in the area are jointly commissioned by the Clinical Commissioning Group and the Council8 6CIT is a test of cognitive impairment that uses an inverse score and questions are weighted to produce a total out of 28. Scores of 0-7 are considered normal and 8 or more significant.

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6.17. A decision was made within the social work team that Adult A was a ‘self-funder’ and was assumed to have mental capacity. There was no further action by Adult Social Care.

Key Episode 3: Discharge to Intermediate Care Bed within Care Home

6.18. Adult A transferred to the Care Home as planned. Copies of discharge summaries accompanied her and a verbal handover was also given.

6.19. Adult A underwent assessments for mobility and continence management. Care Home staff indicated they were not aware of the failed 6CIT test or safeguarding referral on transfer to them. The Intermediate Care Team9, however, working in the Care Home were aware of the safeguarding referral but not the failed 6CIT test from the information that was transferred. The social worker within the team had accessed the record to identify that the safeguarding referral was closed.

6.20. The GP aligned to the Care Home discussed with Adult A whether she would wish to be resuscitated should she suffer a cardiac arrest. During this conversation, the GP did not identify any issues with mental capacity and therefore did not carry out a formal assessment of capacity. Adult A indicated she would not wish to be resuscitated.

6.21. During Adult A’s stay at the Care Home, The Intermediate Care Team were assessing whether they felt that Adult A would be able to return to independent living at home. Assessments were showing that she was independently mobile. There were, however, concerns related to the ongoing behaviour that Adult A would urinate and defecate in inappropriate places. When asked about this behaviour, Adult A appeared indifferent to this and other concerns that were raised with her about her personal care needs.

6.22. The Intermediate Care Team referred Adult A to mental health services via the Primary Care Liaison Service, as it was believed that the behaviour may be due to depression. The Intermediate Care Team were advised by the Primary Care Liaison Service to ask the GP to make a referral. The Mental Health Trust have no record of this conversation with their services.

6.23. The Intermediate Care Team duly asked the GP aligned to the Care Home to review Adult A’s mental health. The GP reported finding no acute mental health problem and felt that ongoing chronic problems should be referred to Adult A’s own GP on discharge.

6.24. The Intermediate Care Team met twice in Multi-Disciplinary Team meetings in the three weeks that Adult A was resident, to discuss progress and to plan discharge.

6.25. The Occupational Therapist undertook a visit to Adult A’s flat with a rehabilitation support worker. The Occupational Therapist was concerned about the unhygienic condition of the property and indicated that a deep clean was required. The riser recliner chair also needed replacement. There were no other identified hazards.

6.26. Adult A declined the deep clean stating she did not want to pay. She declined a new chair even though it was made clear that it could be provided by the NHS. Attempts to assess

9 The Intermediate Care Team is a multi-disciplinary team made up of therapy staff from the local NHS Trust, a social worker from the council, nurses from the Care Home as well as the aligned GP

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Adult A’s ability to cook and care for herself were also declined and she refused to increase her care package on discharge.

6.27. The therapy team indicated at the learning event that they talked at length with Adult A about these issues but could not initiate any change of mind on these aspects of living arrangements.

6.28. Adult A was then deemed to be ready for discharge, mobility having improved. Adult A was expressing a keenness to return home so arrangements were made. The Occupational Therapist contacted the Care Agency who indicated that they could restart the care package on 12th January. It is significant that the Care Agency have no record of this call.

6.29. A referral was made to the community nurses to restart the treatment for leg ulcers and to the Care Coordinator.

6.30. Contact was made with Adult A’s sister and neighbour to inform them of the date of the planned discharge.

Key Episode 4: Discharge Home until Death

6.31. When patient transport services arrived at the Care Home on the afternoon of 11th January, it was clear that they were not going to be able manage to get Adult A into her flat by her walking with assistance. A third member of staff would be required to help carry her into her property up the flight of stairs.

6.32. Patient transport staff were informed by Adult A, that carers or family would be visiting her later that day. On arrival, a neighbour let them into the flat. They ensured that she had her care line pendant and was comfortable and settled before leaving. Patient transport staff report that the flat was not particularly chilly and they left at 2.15pm.

6.33. Adult A activated the care line at 6.00am the following morning; ambulance crew were dispatched. The crew found there was no heating on in the flat, there was mouldy bread and curdled milk in the fridge, it did not appear that the bed been slept in. The neighbour reported that he had seen Adult A the previous afternoon and had thought she seemed confused and that speech was poor.

6.34. The ambulance crew recognised that Adult A was dangerously hypothermic and initiated rapid transportation to hospital.

6.35. Adult A was diagnosed with hypothermia, low blood pressure and in an unconscious state. Adult A was diagnosed with a urinary tract infection and hypothermia. Adult A failed to respond to treatment and died the following day.

6.36. The Ambulance crew recognised concerns regarding poor discharge arrangements and made a safeguarding referral to Adult Social Care.

7. ANALYSIS BY THEME

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The agency reports and learning events provide details of the journey of Adult A. Focussing on the systems that practitioners were working in at the time leads to important information and learning related to multi agency working to safeguard adults.

Assumption of Mental Capacity

7.1. When Adult A was seen on 20th December by paramedics they were concerned about the circumstances that Adult A was found in. There was a lack of food in the flat and there was a significant odour that could be smelt from outside the property. They found trails of faeces around the property and heavily stained chair that Adult A spent most of her time in. Although not a recognised paramedic tool for assessment of cognitive impairment and not a tool for assessment of mental capacity, the paramedic undertook a 6CIT test. The ensuing score of 16/28 indicated a significant cognitive impairment that was worthy of further investigation.

7.2. Whilst this information was passed over to the hospital, it did not result in any further cognitive impairment testing. The apparent high score that would have been indicative of an impairment of cognitive functioning was explained by practitioners at the Learning Event as not unusual for a person found in the circumstances that Adult A had been found in. She was in crisis at that time and may have had a level of fear and confusion.

7.3. During the time that Adult A was at the Acute Hospital, both within the Emergency Department and on the Medical Assessment Unit, there were no physical indicators of cognitive impairment. Adult A was assessed to be largely self-caring. As there was no indication of impairment to the brain or mind at that time there was no indication to undertake a mental capacity assessment. (see also section below: Safeguarding).

7.4. The hospital nursing documentation cites issues of ‘memory loss’ as ‘non-applicable’ but have also logged a self-disclosure by the patient (as part of the dementia screening tool) of having had ‘memory problems over the past 6 months’. This disclosure was not followed up with a cognitive assessment nor made explicit on the Electronic Discharge Summary (EDS). This is likely to have happened because in 2015 the Hospital Trust was embedding the use of the Dementia Screening Tool and at the time practice was inconsistent.

7.5. There is a lack of written evidence that the information regarding the paramedic assessment about the failed 6CIT test and information that Adult A had self-disclosed memory problems was shared in the information handover from the acute hospital. The review process has not been able to confirm if this information was in notes that went from the Acute Hospital to the Care Home, or in the referral information that was in the Access to Care Information.

7.6. It is apparent that neither the Intermediate Care Team nor the Care Home staff had information regarding the failed 6CIT test.

7.7. Staff in the Care Home within the multi-disciplinary team did not have concerns about any cognitive impairment. They were satisfied that they were operating within the principles of the Mental Capacity Act; their interactions with Adult A led them to an assumption of capacity.

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7.8. When the GP aligned to the Care Home met with Adult A on transfer, there were no indications or reports of confusion and no sense of distress or mental impairment. The GP had a conversation with Adult A about whether she would want to be resuscitated in the case for a cardiac arrest. There was no concern expressed about mental capacity to make the decision not to be resuscitated.

7.9. Whilst all the above could be argued to be in line with Principle One of the Mental Capacity Act10 in that there was an assumption of capacity, there were several reasons why this could have been questioned and assessed.

7.10. Adult A had stated, on assessment in the Acute Hospital, that she had some memory problems. The 6CIT test undertaken by the ambulance service should have led to a further testing of cognitive functioning with a view to ruling out any early dementia. Any indicators of cognitive impairment should then have led to a reasoned argument that there could be an impairment of the mind. Under the provisions of the Mental Capacity Act, an assessment of mental capacity would then be required for decisions of care and treatment. This would have led to ensuring that Adult A could be supported in various ways to make decisions. If Adult A did not have the capacity to make a specific decision, then a best interest decision could be made.

7.11. It is recognised that a test of cognitive impairment is not a mental capacity assessment. It is however, argued that any test that indicates a reduction in cognitive ability, could trigger a mental capacity assessment when there may be concern about a decision that an individual is making.

7.12. The Intermediate Care Team were also working to Principle Three of the Mental Capacity Act, that a person is not treated as though they do not have capacity because they appear to be making an unwise decision.

7.13. There were many indicators of self-neglect noticeable from Adult A’s recent history and the circumstances that she was found in. Adult A was also displaying behaviours of urinating and defecating in inappropriate places. She showed little interest in addressing this behaviour or understanding the impact it might be having on her own health and hygiene as well as those of other residents. Adult A was also offered a deep clean of the flat and a replacement riser recliner chair. The deep clean was refused because it would need to be paid for by Adult A. There was no professional curiosity to further explore why Adult A would refuse the offer of a new chair that would be provided free of charge or why she would continue to display behaviours of concern.

7.14. It appears that there was not a deeper understanding of the Mental Capacity Act provisions.

7.15. The Mental Capacity Act Code of Practice11 states that there is provision to allow persons to make decisions that others may believe unwise. It also states, however, there is cause 10 The Mental Capacity Act sets out the five ‘statutory principles’ – the values that underpin the legal requirements in the Act. Principle one states that a person must be assumed to have capacity unless it is established that they lack capacity. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/497253/Mental-capacity-act-code-of-practice.pdf 11 Department of Constitutional Affairs, (2007) Mental Capacity Act Code of Practice available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/497253/Mental-capacity-act-code-of-practice.pdf accessed 13 December 2017

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for concern if someone repeatedly makes unwise decisions that put them at significant risk of harm or exploitation or makes a particular unwise decision that is obviously irrational or out of character. The code states that this does not necessarily mean that a person lacks capacity. They may need more information to be able to help them understand the consequences of the decision they are making or there may need to be further investigation as to whether the person has developed a condition that is affecting decision making.

7.16. There were concerns that Adult A may be depressed and low in mood. The referral, therefore, for input from mental health services was vital to understand if it was a mental health issue that was impacting decision making. There was also a need to pursue any further testing of cognitive impairment. It can be seen that assessment of mental health was required at that point rather than await further input via Adult A’s own GP when she was discharged. This would have informed the discharge planning process ensuring that that Adult A had the capacity to make decisions as laid out in the Act, or that best interest decisions were required to keep her safe.

7.17. In trying to understand why this was the case it appears that staff adhered rigidly to the principles of assumption of capacity and allowing a person to make unwise decisions.

7.18. Information available to this review provides evidence that historically Adult A had been assumed to have Mental Capacity. It does not appear that, as time progressed, this was revisited in order to explain issues of concern or decisions she made.

7.19. Professionals at the learning event repeated that Adult A appeared to understand and be adamant about decisions about what was and was not acceptable to her. There was no indication that professionals considered that the decisions were irrational or that they were putting Adult A at risk of harm. No one within the multi-disciplinary team meetings challenged this stance, suggesting that this was a system wide issue and that there was not a deeper understanding of using the Act to explore mental capacity and decision making further.

Learning Point 1: It is important that professionals are supported to understand the full provisions contained within the Mental Capacity Act. Repeated unwise decisions that put a person at risk of harm should be investigated further. Recommendation 1&6Learning Point 2:Complete and robust handover of all information is vital to inform care when a patient transfers form one service to another. Recommendation 1&6Learning Point 3:Considerations for impairment of the mind or brain need to be assessed fully to inform if further assessment of mental capacity is necessary regarding decisions on care and support needs. Recommendation 1&6

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Understanding Self Neglect12

7.20. It was well known by the services that knew Adult A that she had historically refused services and interventions to improve health and circumstances. Some of this may well have been down to concerns about the financial implication of increasing the care and support package and this is discussed in section 7.37-7.44. It does not, however, explain the behaviours that led to the flat being in such an unhygienic state and that there was very little food within the flat. It was known that Adult A had been diabetic for many years but the food that was evident in the flat was not appropriate food for a diabetic diet.

7.21. It is recognised in research13 and Safeguarding Adult Reviews14 that working with cases of self-neglect can be particularly complex. Since the Care Act15 was enacted in April 2015, self-neglect is a recognised category of abuse that requires safeguarding interventions. In some cases, a Section 42 enquiry is required to protect an adult with care and support needs from harm. In section 7.45-7.69 below the response to the safeguarding alert made by the Ambulance crew and the Acute Hospital will be analysed. In this section, the analysis and learning will focus on the self-neglect element of Adult A’s presentation.

7.22. The research (ibid) recognises that there is a need for practitioners to understand self-neglect and to develop skills in effective interventions. There are four key elements to best practice approaches to working with people who self-neglect:

Importance of relationships Understanding the person Legal literacy Creative interventions Effective multi agency working

7.23. Some of the professionals involved within the Intermediate Care Team did try to establish a rapport with Adult A to try and gain an understanding of why Adult A appeared to be displaying such self-neglecting behaviours. They were not, however, able to gain any understanding or offer any interventions that were successful as they were all refused by Adult A. The Intermediate Care Team indicated that these were longstanding issues that would need to be addressed within the community.

7.24. One of the issues appears to have been that Intermediate Care offers short based interventions and therapy to ensure that a person can maintain independence and return home as soon as is possible. That is precisely the opposite of what research and guidance indicates is the best approaches in working with people who self-neglect. It was not possible within the Intermediate Care Team to establish and develop a relationship

12 Self-Neglect is defined to include people, either with or without mental capacity, who demonstrate: lack of self-care – neglect of personal hygiene, nutrition, hydration and/orhealth, thereby endangering safety and wellbeing, and/or lack of care of one’s environment – squalor and hoarding, and/or refusal of services that would mitigate risk of harm.

13 Braye, S. Orr, D. & Preston-Shoot, M. (2015) Self-neglect policy and practice: key research messages. Social Care Institute for Excellence available at https://www.scie.org.uk/publications/reports/report46.pdf accessed 14 December 201714 Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Learning lessons about self-neglect? An analysis of serious case reviews’, Journal of Adult Protection, 17, 1, 3-18 15 HM Government, 2014, The Care Act, London The Stationery Office

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with Adult A that would be ongoing.

7.25. It was not clear from the agency reports provided for the review or any of the conversations at the Learning Event, that there was any detailed history regarding Adult A or an understanding of the person. Despite the short-term interventions and refusal of services, there were missed opportunities by health and social care to undertake a detailed history. This was needed as a starting point to understand something of the possible triggers and causes of the self-neglecting behaviour. The reason for very little input from adult social care was cited as being because Adult A was self-funding. This will be covered within the section on financial elements.

7.26. Indeed, there is some information that Adult A had worked on an air base in earlier life and at some point, had become widowed. These areas were not explored further and the approach appeared to be dealing with the here and now. Understanding the person in an empathetic way can support the development of a trusting relationship.

7.27. Adult A’s nephew stated that he did not know of the self-neglecting behaviours or the issues that have been raised about toileting behaviour. He is of the view that this was not ongoing behaviour and was not anything that he had been informed about. There may well have been missed opportunities to understand and explore that in fact, this was a recent issue and not longstanding behaviour as believed by some professionals. This view would be supported by the fact that the community nurses, ambulance staff or carers had not raised this as a concern in earlier visits in December. There is, however, evidence in earlier (pre-scope of this review) referrals to Adult Social Care of un hygienic conditions but possibly not the severity of issue found on 20th December.

7.28. Historic information regarding unhygienic conditions and refusal of services that agencies were aware of did not appear to have led to further exploration of these behaviours. There does not appear to have been any sharing of information at this early stage to or from the GP practice. This is looked at in 7.32 below (multi agency working in self neglect).

7.29. The section above details why and how the Mental Capacity Act was an important element in understanding the self-neglecting behaviour. The view was that Adult A had capacity, that she was making unwise decisions under the provisions of the Act and that it was a lifestyle choice. Whilst it is not best practice to use legal interventions unnecessarily, it is important to apply the provisions within the Mental Capacity Act to understand and underpin practice. The interventions that were possible might have differed dependent upon the mental capacity of the Adult A. Assumption of capacity therefore had an impact on practice regarding self-neglect.

7.30. There was also other historic evidence from Adult A that the self-neglecting behaviours may not be lifestyle choices. There had been contact from the Care Coordinator and Adult A herself, requesting an increase in the care package thus suggesting that further help with self-care had been requested but effectively refused because of the self-funding issue.

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7.31. It is recognised that there is no magic answer to interventions that work in all cases of self-neglect. There is a need to be flexible given the different types of behaviours that may be present. This review would suggest that the interventions that were offered were not especially creative but would have gone some way to improving the conditions in the flat. Had this not been left to Adult A to fund, they may well have been accepted. An exploration as to whether funding could have been found elsewhere, may have resulted in positive responses from Adult A.

7.32. What may have made a difference with Adult A could have been more cohesive multi agency working. It is acknowledged that the Intermediate Care Team was not working in the most effective manner at the time that Adult A was at the Care Home. The Multi-Disciplinary Team meetings were not well minuted, albeit that it was reported that the social worker, nurses and therapy staff would have been present. This led to difficulties in communication of actions required. There was no key worker system for residents which compounded communication difficulties. It is of note that due to the self-funding status, Adult A was not open to Adult Social Care. The social worker role within the meetings, therefore, was deemed to be one of note taking. It is pleasing to note that changes have now been made to the Intermediate Care Team processes. Meetings are now formally minuted and each person has an allocated key worker.

7.33. There was scope to include a wider multi-agency team as well as family to plan interventions and care regarding Adult A’s self-neglect. There is recognition that there needed to be a focus on relationship building and understating of Adult A. The Intermediate Care Team could not facilitate any long-term work so forward planning and creativity were needed to establish how that might be provided. The GP practice and the care agency had information from 2014 that would have been useful to have known and discussed as part of the understanding of the self-neglecting behaviours. Involving the GP, therefore, and the community nurses as well as the Care Agency who were going to be picking up the care on discharge was crucial to discharge planning and planning self-neglect interventions.

7.34. There did not appear to be any record of professionals addressing the apparent neglect of managing diabetes or the risks of harm that eating inappropriate foods and therefore not managing the condition would have on health and well-being.

7.35. It appears that staff did not have a good understanding of self-neglect and how to approach dealing with Adult A’s self-neglecting behaviours. There is currently no self-neglect guidance in place in Wiltshire and there has been no adoption of any national practice guidance locally or any training for staff working in this complex area.

7.36. The systemic way services are offered also impedes work in self neglect; there is pressure on many services to ensure that interventions and services are short term in nature. Clearly cases should not stay open to health and social care teams longer than is necessary. This calls for consideration of how this works in cases of self-neglect and requires ownership at a strategic level. An understanding is required of the scale of self-neglect work and services should be commissioned to offer long term work to support

Learning Point 4:Self Neglect work is complex and requires guidance and support for staff to manage and understand best practice approaches. Recommendation 2 &6Learning Point 5:Working in cases of self-neglect requires effective multi agency working and planning Recommendation 2 &6Learning Point 6:Commissioners can have a role in understanding the scale of self-neglect and ensuring a strategic approach that recognises the longevity of work that is required in achieving positive outcomes. Recommendation 2 &6

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staff to manage self-neglect.

Impact of Self-funding on Care and Support Assessment

7.37. It was in 2009 that Adult A was first assessed by Adult Social Care to identify care and support needs. Agency records would suggest that at this time care was funded by the local authority and that it was not until 2012 that this changed. Continued referrals were made to social care but did not trigger a review due to Adult A being classed as a self-funder. There is no evidence that Adult A was informed of the possibility of a reassessment should care needs increase.

7.38. Whilst this period was out of the scope of the review it appears to have had an impact on the period within the scope of this review. The historic information that Adult A was self-funding was not revisited and did not lead to further assessment. Her status, therefore, did not change.

7.39. Adult Social Care, in their agency report, identified that in fact Adult A should have been classed as a ‘full cost payer’ as opposed to a ‘self-funder’. Adult A did not have capital more than the threshold at that time to be classed as self-funding. It was because the level of cost for care was very low, and less than the assessed contribution that Adult A was required to make, that she funded all the care package at that time herself. As there was no reassessment, this error in historic information was not discovered and the self-funding status remained.

7.40. The safeguarding referrals did not follow the appropriate processes (analysed in the next section) and were passed to an adult social care team for a care and support assessment. Again, this was not undertaken because Adult A was a self-funder. The missed opportunity here was also a significant one. There were details regarding financial abuse and this could have been a trigger to really assess and understand why Adult A was reluctant to pay for care, investigate whether there were links to the allegation of financial abuse, reassess Adult A’s required contributions to care, and indeed whether Adult A had the capacity to understand her financial situation. The paramedics reported that there were several bank statements on the kitchen table that could have indicated that Adult A was concerned about her finances.

7.41. A proper investigation into the financial abuse or a reassessment of finance and benefits as part of a review of care and support needs was needed. Professionals at the Learning Event identified that, in fact, from evidence given at the inquest, there was no money missing. This is obviously from a hindsight position and what was evidenced after Adult A’s death. Adult A’s confusion regarding the financial situation would have become apparent during an investigation or assessment. This could have then led to questions regarding Adult A’s mental capacity to understand and manage her financial affairs.

7.42. Under Care Act (2014) (Section 9) arrangements, clients are entitled to care and support assessments regardless of whether the local authority eligibility criteria for funding is reached. Statutory care and support guidance requires that eligibly criteria for funded care, details of what self-funding means as well as signposting to independent financial advice are made available to clients and families following assessment that a person will be funding all or part of their care.

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7.43. Prior to the Care Act being enacted in April 2015, Adult A was still eligible for ongoing review of care and support needs under the previous legislation, NHS and Community Care Act 1990 Section 47.

7.44. There appeared to be an acceptance by those making referrals for increased support, that the given reason for not offering further review of care and support being self-funding was valid and was not challenged. This compounded the decisions that were being made.

Application of Safeguarding Procedures

7.45. As is often the case when omissions lead to failures in the system, there was a lack of robust application of safeguarding procedures and sharing of information evident in more than one agency.

7.46. The initial safeguarding referral from the paramedics on 20th December was not a direct referral from the paramedic that had attended Adult A’s flat. Due to the large area that the Ambulance Service covers and the different local authority referral procedures, ambulance staff do not use the multi-agency safeguarding referral forms that are available. The member of staff that identified the issue did not make the referral.

7.47. This leads to two issues. The member of staff is required to pass the information of the concern to the clinical desk at the control centre. The information is therefore passed to a third party and relies on the information being accurately transferred verbally and understood. This information is then entered onto a proforma and sent to Adult Social Care. The form is the same form that is used to highlight various concerns, not all of which would constitute safeguarding. There is no indication that the form constitutes a safeguarding alert and relies on the person reading the information to discern that the concern relates to safeguarding. There are therefore issues within this system that are vulnerable to misinterpretation and a lack of clarity of purpose.

Learning Point 7 : Self-funding status of clients is not a barrier to reassessment of care and support needs. Recommendation 3 &6Learning Point 8 :Incorrect terminology regarding financial status can lead to ongoing impact of care and support Recommendation 3 &6Learning Point 9:Clients who are self-funding need clear information about what self-funding entails and what would trigger further consideration of threshold of care and financial contributions. Recommendation 3 &6Learning Point 10:Clients who are self-funding need information and signposting to where they can get independent help and support to understand their financial assessment e.g. Age UK etc. Recommendation 3 &6Learning Point 11:All professionals need to challenge decisions where they believe a person is left at risk of harm due to a decision not to review care and support needs. Recommendation 6

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7.48. There were gaps in the information passed from the Ambulance Service to Adult Social Care. This can be seen when compared with the discussion between the paramedic and the out of hours GP. Significantly, these gaps related to the financial abuse.

7.49. During the Learning Event, there were discrepancies about the allegation of financial abuse. Some professionals believed that the amount that Adult A had said was missing was £40,000 and some believed it to be other lesser amounts of £50 or £5,000. What is apparent from the call from the paramedic to the GP out of hours’ service, is that there were copies of bank statements all over the kitchen table, indicating that it was a significant worry for Adult A and one that she disclosed to the paramedic.

7.50. In the case of this referral, the Emergency Duty Team assessing the out of hours’ referral, decided that the request was for a care and support needs assessment and not a safeguarding referral. The explicit identification of self-neglect and financial abuse allegation was not picked up by the person reading the referral as the information was not explicitly identified as such. It was therefore passed to an adult social care team for assessment rather than the Adult Safeguarding Team for investigation. Therefore, neither the self-neglect element or financial abuse as categories of abuse that could have led to a Section 42 Safeguarding enquiry were triggered.

7.51. Understanding how the referral was made and how it was received leads to opportunities to understand why the system has those vulnerabilities and how the referral did not have an appropriate response.

7.52. It is of note that the ambulance service has invested in mobile working technology in 2015 with the ability to make direct referral using this technology. The paramedic on 20th December used the old system of referral. Visiting paramedics on 12th January, however, used the new system and noted significant improvement in quality of referral. The Ambulance Service have indicated that procedures have changed. All referrals are now made using electronic methods by the paramedic who has identified the concerns. These go directly to the Ambulance Service safeguarding team for onward transmission and oversight to Adult Social Care. The use of the clinical desk may still be used in times of electronic failure or major incident.

7.53. The Acute Hospital Trust also made a safeguarding referral based on the handover and information available from the Ambulance Service. On this occasion, although the system within that hospital is robust, it was an agency nurse who made the referral on instruction by the sister in the Emergency Department. Whilst making the referral was good practice, by not understanding the referral process, it did not go to the required destination. The back-up system of ensuring all safeguarding referrals are sent to the safeguarding team in the hospital, was not known to the agency nurse and therefore the referral was unknown to the hospital safeguarding team. The referral had been sent by fax but was never received by Adult Social Care. The safeguarding team, not knowing of the referral, did not chase the outcome. The agency nurse may not have been on shift the next day to chase for herself, therefore the fact that it was never received was not known. The information in the referral suggested the financial abuse that had been reported by the ambulance service. Had this referral reached its destination, the financial abuse allegation would have been known to Adult Social Care despite the fact that it was not explicit in the referral from the Ambulance Service.

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7.54. The Acute Hospital Trust referral also indicated that Adult A had no family or Next of Kin, which was incorrect information.

7.55. The Acute Hospital have indicated there is now a new system of referral within the Trust that does not rely on fax but is via email. There are also display boards within the Emergency Department indicating the safeguarding process. The Acute Hospital recognises that although this is an improvement, it is not possible to be clear that the issue could not arise again given the large numbers of temporary staff that work in the Trust. There are also several policies and procedures that the Trust has that temporary staff need to be inducted in, even for one shift.

7.56. Adult Social Care have identified a recommendation in their single agency report to ensure that Emergency Duty Team are trained in the recognition of safeguarding issues that require a referral for a Section 42 Enquiry. These referrals need to go the Safeguarding Adult Team.

7.57. An Adult Multi-Agency Safeguarding Hub (MASH)16 is currently being developed in Wiltshire and will commence operation in May 2018. It is recognised that this way of working will increase the recognition of safeguarding issues and that it will be a multi-agency discussion regarding an appropriate response to referrals.

7.58. Neither safeguarding referral contained any element of the Making Safeguarding Personal (MSP) requirement of the Care Act. This requirement is also included in the Wiltshire Safeguarding Adult Board Policies and Procedures for Safeguarding. The ethos of the Care Act (Section 42, Safeguarding) and Care and Support Statuary Guidance Chapter 14 (Safeguarding) is that safeguarding adults’ activity must be person centred using a MSP approach. Working to these principles ensures that the safeguarding process is person led rather than process driven.

7.59. There is no evidence that any of the professionals who either made referrals or were aware of those referrals discussed the nature of the content within the referrals with Adult A or ascertained what outcomes she would want to see to safeguard her in the future.

7.60. The reasons cited were that the ambulance crew needed to concentrate on the immediate safety and ensure that Adult A was conveyed to a place of safety and that there was evidence within their assessment that there was a cognitive impairment so did not give weight to the MSP approach.

7.61. The Acute Hospital cited reasons that the emergency department is very busy and there is not always an ability to find time to discuss the referral in advance and that onus is put on making the referral.

16 Multi-agency safeguarding hubs are structures designed to facilitate information-sharing and decision-making on a multi-agency basis often, though not always, through co-locating staff from the local authority, health agencies and the police. Such hubs in adult safeguarding can prove effective in preventing abuse, and spotting patterns of abuse and repeat offenders though effectively sharing information.https://www.scie.org.uk/care-act-2014/safeguarding-adults/safeguarding-adults-boards-checklist-and-resources/collaborative-working-and-partnership/multi-agency-safeguarding-hubs.asp accessed 26 January 2018

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7.62. Central to the MSP approach is also the understanding of mental capacity i.e. does the person have the capacity to decide on their own protection from harm.

7.63. This review would argue that MSP approaches can be used in all circumstances and should not be seen as optional. This review suggests that in order to make a robust referral it is necessary to at least have a conversation with the adult about their circumstances and why there are concerns.

7.64. There is also some learning from the safeguarding referral on 12th January. This was made by the paramedics due to concerns that Adult A had only been discharged on the afternoon of 11th January and was found in a cold flat, with no heating on and with not fresh food in the flat.

7.65. The referral was received by the Safeguarding Adult Team and passed to Adult Social Care Team. Following the death of Adult A, a social worker was allocated to identify what had happened in the case.

7.66. The information gathered from the Intermediate Care Team identified that Adult A was an adult with capacity who was self-funding. Information stated that she had a history of refusing care and intervention. It was also identified that the case was subject to a coroner’s investigation. The safeguarding investigation was closed at that point.

7.67. The issues that this review has found were seen again here i.e. limited understanding of Mental Capacity, impact of funding status and not then not recognising that this was a case of self-neglect. This then impacted on any recognition of a case that would meet the criteria for a Safeguarding Adult Review.

7.68. There was no consideration that the case should be referred for consideration of a Safeguarding Adult Review by any of the agencies that became aware of the circumstances. It was not until receipt of the Regulation 28 reports that there was a recognition that a SAR should be considered.

7.69. Paragraph 2.1 in Appendix One (Terms of Reference) identifies the circumstances under which a review should be considered and this case does meet the criteria. It is of note that there is a paragraph in the WSAB Policy and Procedures for Safeguarding Adults in Wiltshire related to SARs. The WSAB Safeguarding Adult Review Learning and Improvement Policy, which identifies that circumstances and processes for a SAR, was not applied as early as it could have been.

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Planning for discharge

7.70. Much of the element above impacted on ensuring that Adult A was discharged in a safe and supported way and at the right time.

7.71. The British medical journal17, albeit taking about hospital discharge, has some helpful guidance information about discharge planning that dates back to 2008. It asserts that:

Discharge planning aims to improve the coordination of services and care after a patient’s discharge

Good planning requires anticipation of potential problems by good information gathering, early resolution of potential barriers to discharge, and timely referral to the multidisciplinary team

Planning involves close collaboration between the patient, the family, and the multidisciplinary team; this leads to improved patient and carer satisfaction

7.72. Due to the number of patient safety incidents, NHS England issued a patient safety alert in August 201418 that cited concerns as follows:

Review of these incidents identified that patients are sometimes discharged without adequate and timely communication of essential information at point of handover to all relevant staff and teams in primary and social care, including out of hours, and that information is not always acted on in a timely manner. This can result in avoidable death and serious harm to patients due to a failure in continuity of care as well as avoidable readmission to secondary care.

7.73. It is therefore important to understand why Adult A was discharged in the way that she was and that less than 48 hours later she had died in the circumstances that she did.

7.74. In this section, it is the coordination of the discharge process that requires further analysis. It is discussed in 7.33 that having the right professionals within the Multi-Disciplinary Team meetings when working with people who self-neglect is important. It is

17 BMJ 2008;337:a2694 available at http://www.bmj.com/content/337/bmj.a2694 Accessed 15 December 201718 NHS England (2014) Patient Safety Alert: Risks arising from breakdown and failure to act on communication during handover at the time of discharge from secondary care available at https://www.england.nhs.uk/wp-content/uploads/2014/08/psa-imp-saf-of-discharge.pdf accessed 15 December 2017

Learning Point 12: Ensuring robust information is shared in referrals and reason for referral is explicit is important in eliciting an appropriate response. Recommendation 6 Learning Point 13:Organisations who employ temporary staff need to ensure there is access to and clarity of processes and procedures. Recommendation 6Learning Point 14:Making safeguarding personal is at the forefront of adult safeguarding activity and a fundamental part of the Care Act and is not optional. Recommendation 6Learning Point 15: All agencies require knowledge of the criteria for a consideration of a Safeguarding Adult Review and their responsibility to make appropriate referrals. Recommendation 4 &6

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also important when planning discharge.

7.75. There was a focus on Adult A having capacity to make decisions about care and support. She had refused to pay for any extra care including a deep clean of her flat. Whether she was receiving the right package of care and issues regarding reassessment, mental capacity and funding are all argued above.

7.76. The Intermediate Care team had visited Adult A’s flat and deemed it to be a safe environment. The deep clean and new chair had been declined, however, and Adult A had refused and assessment of her ability to cook and make drinks.

7.77. The Community Health Trust identified that they had not been able to access the records in order to identify what risk assessments were undertaken or evidence care that was delivered. The Intermediate Care Team indicated the usual processes that were undertaken when assessing a person who was admitted for rehabilitation. It was noted in the case of Adult A, from recollection and by using the coroner’s court statements, that she was independently mobile with a walking stick and that this had been replaced by a wheeled zimmer frame following assessment by the physiotherapist. It is noted that Adult A often used furniture to support her mobilisation and had to be reminded to use her frame.

7.78. There were many aspects that the team had identified in their own discharge and rehabilitation planning for Adult A that she refused. It is not evident that this was escalated or discussed in supervision or with management.

7.79. The Intermediate Care Team state that they contacted the Care Agency and had ensured that discharge was planned to coincide with the care package restarting. It was identified that the care package could restart on 12th January. Adult A was discharged on the afternoon of 11th January. There appears to have been a communication error here as the Care Agency have no record of knowing about Adult A’s discharge. This is significant in the circumstances as they were not aware that the care package was to restart. Even without the rapid decline in health for Adult A post discharge, there would have been no carers visiting Adult A. It is not possible for this review to state when this would have been identified.

7.80. The communication error has not been resolved. The Care Agency are subcontracted to another provider and it has not been possible to identify where the error occurred.

7.81. The team had also informed the sister of Adult A, the date of discharge as well as the neighbour who had previously offered care and support. Patient Transport Service was also arranged.

7.82. Missing from these communications was what the expectations that were implicit in this information being shared. Having written discharge plans that were signed up to by all concerned was required. At the very least there should have been written confirmation of the care package restarting.

7.83. The Intermediate Care Team assumed that by sharing the above information that family and friends would ensure that Adult A was cared for. This included that heating would be

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put on and that food would be bought. Adult A’s sister lived some miles away and was elderly herself. The neighbour also had health issues.

7.84. The Community Care Trust have set an action to review the discharge policy and procedure to ensure that it covers community teams. The Intermediate Care Team also now use an Intermediate Care Team multidisciplinary team discharge checklist. The author has been assured that the policy covers all the areas of learning regarding discharge issues that this review has identified.

7.85. The nephew of Adult A informed the lead reviewer that the family were not made aware of the discharge date by any professional. They had received a call from Adult A asking if the family could collect her on discharge but no date was discussed. Adult A’s nephew told her that this was not possible. This was due to the distance and that Adult A would not be able to get into her flat as she could not manage stairs.

7.86. It is important to note that Adult A was being discharged to a situation that had caused previous concern with no apparent changes being made. Adult A was discharged on a winter’s afternoon to the flat where she lived alone and could not leave. Although the UK average mean temperature was 0.9 degrees above the mean average of 4.6 degrees in January 201619, this was still cold.

7.87. It was noted by the Intermediate Care Team that Adult A’s mobility had improved whilst in the care home. She was independently mobile using appropriate aids. When Patient Transport services arrived, they found that she could not manage stairs even with assistance and had to be carried back into her property. A stair assessment had not been completed by the Intermediate Care Team as Adult A stated that she did not leave her property.

7.88. It does not appear that suitability of the property that Adult A lived in was discussed to identify if it remained safe environment given her needs. Staff from the Intermediate Care Team stated that Adult A wanted to return and did not indicate that she didn’t think this was suitable for her any longer. No professional challenged this or assessed if the property, on the first floor with no lift access was an issue for someone who could not manage stairs. The reason this was not challenged was because staff were working under principles one and three of the Mental Capacity Act as previously stated. This effectively made her house bound. Consideration of this issue should have been evidenced in discharge planning, underpinned by a mental capacity assessment and recording of a best interest decision.

7.89. Patient transport services staff identified that the property did not appear too chilly. This was based on the staff experience of taking patients home. The author would suggest that this is a subjective view and not based on factual evidence.

7.90. Adult A had been cared for in an environment that was possibly very warm, as it was a care home, for the previous 21 days, whilst her flat had been empty. The author would argue that It would have been good practice to check the temperature of the property and that the heating was on or at least have asked the neighbour to check (possibly had the same heating system as lived in same block). Patient transport services have suggested that this is the role of the discharging team to ensure that the accommodation 19 Met Office Reports January 2016 https://www.metoffice.gov.uk/climate/uk/summaries/2016/january Accessed 01 March 2018

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is suitable.

7.91. Patient Transport Services identified that the crew that took Adult A home were very experienced and were all trained in safeguarding. They had no doubt regarding the information that Adult A told them regarding care that was due later that day from family, carers and neighbours. It is now known that this was not the case, albeit that Adult A appeared credible in her story. Patient Transport Services work on the basis that as transport has been booked, that all suitable arrangements have been made by the organisation that has prepared and planned the discharge.

7.92. Given the learning from this review, the author would suggest that it would be reasonable to ask that transport staff check that heating is on, if appropriate. This should be part of the checks that the environment they are returning a person to is not going to be causing immediate danger. Patient Transport Services have duly made a single agency recommendation to ensure that the learning from this review is included in their future safeguarding training.

7.93. The Intermediate Care Team argued that there was no reason to suspect that heating was not on as there were storage radiators that would come on automatically. The author would challenge this as a risky assumption.

7.94. It was also discussed, and this review accepts that, the hypothermia may well have been due to sepsis from the infection that was identified on admission to hospital and not necessarily due to a cold flat.

7.95. Notwithstanding both of these issues it is known that when ambulance staff attended on 12th January, they reported that there was no heating on and the flat was cold.

7.96. It is now apparent that there were no definite arrangements in place to ensure that Adult A had what she required on discharge and arrangements were based on assumptions. In the case of the Care Agency, arrangements were not in place as far as they were concerned.

7.97. It is hopeful that the new discharge planning arrangements in place will prevent future issues of this nature occurring. A multi-agency recommendation is made in respect of monitoring discharges of adults with care and support needs who live alone.

7.98. This review recognises the coroner’s findings and the issues that contributed to Adult A’s death. It is not possible to know why Adult A did not have heating on. The community nurses that had previously visited, have informed this review that the flat was always warm when they visited.

7.99. It is recognised that it was infection that caused Adult A’s collapse. The decline in Adult A can only be assumed to have been rapid as on the day of discharge there were no identified symptoms of infection by those that had contact with her.

7.100. It is, however, recognised that even without an infection, the self-neglect issues had not been addressed. The outcome for Adult A in the longer term was likely to be poor. She was ostensibly discharged back to the same circumstances as before, having been seen

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as refusing interventions that may have made a difference.

7.101. This review has not found that Adult A was ready to be discharged back to independent living. Albeit that it was what she wanted, she did not appear to be able to care for herself with the level of care package that was in place. It does not appear that the circumstances were any different circumstances than prior to her admission to an intermediate care bed. The reasons given for the failure of rehabilitation were accepted; solutions were not explored.

8.

GOOD PRACTICE

8.1. It is important to note that most practitioners offer a good level of service to their clients/patients and follow policies and procedures that are provided to guide practice. Whilst recognising gaps in practice, Safeguarding Adult Reviews can also provide evidence of this as well as practice that goes over and above what is expected. Agency Reports and attendees at the Learning Events were asked to identify these from their own and other agencies. It is important to highlight these as areas where learning can occur and to recognise good practice.

Ambulance staff recognised that the circumstances that Adult A was living in possibly constituted a safeguarding issue and alerted Adult Social Care services via their recognised referral pathway.

The intermediate Care Team Occupational therapist attempted to ascertain the reasons for Adult A’s presenting behaviour. Arrangements were made to ensure a suitable and timely discharge as Adult A was keen to go home and to maintain as much independence for Adult A as possible. There were many reasons discussed above why this did not have the desired outcome.

The intermediate Care Team provided a basis for inter disciplinary collaboration. The Care home provided a good level of Care to Adult A and for 21 days Adult A

was safe and well cared for. Staff working with Adult A attempted to work within what Adult A wished. Staff within the Intermediate Care Team worked hard to improve Adult A’s

mobility to improve outcomes. The intermediate Care Team did try to look at the life history of Adult A, but this

was a time limited placement and as detailed above, this often takes time. The access system to intermediate care beds ensured that Adult A could

maintain independence as opposed to being hospitalised. There was evidence of some robust assessments within a short period of time

within the care home.

Learning Point 16: Communication and coordination is key to effective and safe discharges. Recommendation 5 &6Learning Point 17:Discharge plans need to be written and shared with all those who are to be involved in providing ongoing care. Recommendation 5 &6Learning Point 18:Clarity of requirements of all those who will be providing ongoing care (paid and unpaid) must be evidenced and documented to avoid assumptions particularly when a person lives alone and it is winter e.g. who will be ensuring food and heating is available. Recommendation 5 &6

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There was evidence of good multi agency working on the day that Adult A was admitted. The Access to care service identified an intermediate care bed within twenty minutes of receiving referral. Hospital staff to provided a place of safety to address immediate concerns until the intermediate care bed became available.

The Agency nurse at the hospital recognised the safeguarding issues and put in a safeguarding alert albeit that the process was not well understood.

The Care coordinator role in primary care appeared to be a positive role and had been aware of Adult A for sometime, making numerous requests for further support.

Early assessment of care and support needs attempted to offer support based on what was important to Adult A.

9. CONCLUSIONS AND LESSONS LEARNED

9.1. This case has identified a number of issues, some of which may not have resulted in significant harm if they had occurred in isolation. There are some similarities with the ‘swiss cheese model’, which may help understanding of how risk developed around Adult A (See Appendix Two).

9.2. The layers of the model are all the processes that are designed to ensure the right services are in place. When followed they provide defences in the system that lead to safety. When those layers all have breaches, at the same time, the vulnerabilities in the system align and catastrophic errors occur.

9.3. It is striking in this case how all the systems relied heavily on each other and are inextricably linked.

9.4. The assumption of capacity and allowance for unwise decision making are key principles of the Mental Capacity Act. These were applied without understanding of when these should be called into question.

9.5. That then impacted on the understanding of the self-neglecting behaviour and further assumption that this was merely an unwise lifestyle choice. Thus, there was not a thorough assessment regarding any impairment of mind or brain that would then trigger mental capacity assessment.

9.6. Best practice guidance around self-neglect was not applied. A deeper understanding of Adult A as a person was not gained. The history, including the start of the self-neglecting behaviour was not fully appreciated. The impact of her not wanting to spend money was unnecessarily missed.

9.7. The assumption of capacity led to assumption that Adult A could make effective decisions related to her healthcare (i.e. management of her diabetes and mobility treatment choices).

9.8. Seen as an adult who was a self-funder, had capacity and was making unwise decisions then prevented a robust review of care and support and financial contributions.

9.9. The discharge planning process was another layer of defence that failed. It did not involve all the professionals and family in any way that was cognisant of best practice in

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working with self-neglect. It did not adhere to best practice in managing safe discharges. Indeed, this review suggests that the period spent in intermediate care did not achieve the desired outcome in ensuring that Adult A could return to independent living safely.

9.10. A further layer of defence was the failure of application of robust safeguarding procedures by several agencies. The Acute Hospital Trust did not follow procedure, the Ambulance service did not transfer the right information in order to trigger a safeguarding response and the Emergency Duty Team in Adult social care did not recognise safeguarding issues in the first referral. No Agency considered a SAR following the second referral in January and relied on the coroner’s inquest to identify issues.

9.11. There were other elements of practice that could have had an impact on all the above that may have provided a change in the system and may have affected the outcome.

9.12. The professionals that were interacting with each other did not challenge decisions that were made in other agencies. There was no evidence of escalation when referrals were not receiving the expected response. (E.g. safeguarding referrals, referrals for increased care, referrals to mental health team for assessment). Challenge and escalation can be key responses that invoke a change and review of actions and decisions.

9.13. Professionals were struggling to understand the behaviour of Adult A. Services were being declined. There is no evidence that these were discussed with managers or in supervision as a way of eliciting support and guidance for ensuring safety of Adult A. Management oversight and supervision can give practitioners valuable support in difficult situations.

9.14. It can therefore be seen that there were several identified elements that impacted on the outcome for Adult A. It could be considered that ultimately, it was the discharge planning that was the final layer of defence that failed. That, however, relied on all the other elements being effectively applied to understand what exactly needed to be part of the discharge plan and future interventions. If these had been applied robustly, Adult A may well not have been discharged at all at that time. There were many layers of protection in the system that failed at the same time culminating in a catastrophic outcome for Adult A.

10. RECOMMENDATIONS

10.1. Where agencies have made their own recommendations in their Agency Reports, WSAB should seek assurance that action plans are underway and outcomes are impact assessed within those organisations.

10.2. This review has sought further single agency recommendations from several agencies identified in the body of the report where relevant.

10.3. The following multi agency recommendations are made to the WSAB as a result of the learning in this case:

1. WSAB must assure itself that agencies can evidence how they will address the shortfalls in understanding and application of the Mental Capacity Act that this review

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has evidenced. (Learning Points 1-3)

2. WSAB should produce Multi Agency Self Neglect guidance to support practitioners in managing self-neglect. This should include all learning points related to self-neglect. (Learning Points 4-6)

3. WSAB should seek assurance from agencies that clients (where appropriate) and practitioners are supported to understand financial status under which care is being provided and are cognisant the learning points in this review. (Learning Points 7-10)

4. WSAB should refresh and re launch the SAR Learning and Improvement Policy and publish it on the Board Website. (Learning Points 15)

5. WSAB should seek patient stories and undertake audit showing evidence of the effectiveness and safety of discharge planning processes for people with care and support needs (Learning Points 16-18).

6. WSAB should provide a learning briefing to all agencies regarding all the learning points from this review. Audit of evidence of circulation should be undertaken. (Learning Points 1-18)

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Appendix One: Terms of Reference

1. Introduction:1.1. Adult A was found in a situation of serious self-neglect in her flat having activated

her lifeline. She had been discharged from hospital only weeks before this. Paramedics transported her to hospital, where she died. At the time of her death she was suffering from hypothermia, broncho pneumonia, left ventricular hypotrophy, hypertension, type 2 diabetes, chronic kidney disease and dementia.

1.2. This Safeguarding Adult Review is commissioned by Wiltshire Safeguarding Adults Board following an inquest which considered the specific matters which contributed to Adult A’s death. The aim of the review is to establish whether there are any lessons to be learnt about the way in which local professionals and agencies worked together to prevent and reduce abuse and neglect of adults.

2 Legal Framework:

2.1 The Care Act 2014 states that Safeguarding Adults Boards (SABs) must arrange a Safeguarding Adults Review (SAR) when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. SABs must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect.

In addition to the above SABs might select cases for either of the reasons noted in the statutory guidance:

1. Where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults

2. To explore examples of good practice where this is likely to identify lessons that can be applied to future cases

2.2 The purpose of the SAR is to promote effective learning and improvement action to prevent future deaths or serious harm occurring again. The aim is that lessons can be learned from the case and for those lessons to be applied to future cases.

3. Methodology:

3.1. This Case Review will be conducted using the Significant Incident Learning Process (SILP) methodology, which reflects on multi-agency work systemically and aims to answer the question why things happened. Importantly it recognises good practice and strengths that can be built on, as well as things that need to be done differently to encourage improvements. The SILP learning model engages frontline practitioners and their managers in the review of the case, focusing on why those involved acted in a certain way at that time. It is a collaborative and analytical process which combines written Agency Reports with Learning Events.

3.2. This model is based on the expectation that Case Reviews are conducted in a way that recognises the complex circumstances in which professionals work together and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight.

3.3. The SILP model of review adheres to the principles of;

• Proportionality

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• Learning from good practice• Active engagement of practitioners• Engagement with families• Systems methodology

4. Scope of Case Review:

4.1. Adult A

4.2. Scoping period: from December 2015 [safeguarding alert] to 13th January 2016 [date of death]

4.2. In addition agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of these adults. This could include a significant event that falls outside the timeframe if agencies consider that it would add value and learning to the review’s Terms of Reference. This will include historic context of agency involvement as well as actions which could have been taken post death when contact was received from the Coroner.

• Agency Reports:

5.1. Agency Reports will be requested from:

GP The Care Home

• Police

• Mental Health Partnership NHS Trust

• The Hospital Trust

• The Community NHS Trust

• Adult Social Care

• Ambulance Trust

5.2. Agencies are requested to use the attached Report Template.

• Areas for consideration:

6.1 What assessments were carried out and how robust were these in terms of meeting any assessed need? Was Adult A’s self-neglecting behaviour considered from a person centred perspective?

6.2 How were assessments communicated to others who were providing care for Adult A? How did assessments inform plans at various points during Adult A’s journey?

6.3 Was the Mental Capacity Act applied correctly and at appropriate intervals? 6.4      What was the understanding within your agency of the safeguarding alert

received in December 2015? What was the rationale for further action not being taken? Was challenge or escalation considered at this point?

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6.5 What was understood within agencies about the relationship between Adult A and her carer? Please analyse the way in which any position of trust or financial issues were identified or investigated?

6.6 Were opportunities missed to undertake visits or to take or apply external advice?6.8 Please include within your agency report any response you made to the coroner’s

matters of concern, including any action plan. 6.7 Identify examples of good practice, both single and multi-agency.

7. Engagement with the family

A key element of SILP is engagement with family members, in order that their views can be sought and integrated into the Review and the learning. WSAB has already informed Adult A’s family that this Case Review is being undertaken. The independent reviewers will follow up by making contact with Adult A’s sister and nephew to explain the reviewers involvement and offer an opportunity to contribute to the review.

Further contact will be made to invite them to participate in the form of a home visit, interview, correspondence or telephone conversation prior to the Learning Event. Their contribution will be woven into the text of the Case Review Overview Report and they will be given feedback at the end of the process.

8. Timetable for SAR :

Scoping Meeting 13th September 2017 at 11.15am

Letters to Agencies 26th September 2017

Agency Report Authors' Briefing 28 September 2017 at 11.15am

Engagement with family Begin September 2017 once authorized

Agency Reports submitted to WSAB 28 November 2017

Agency Reports quality assured by chair 28-30 November 2017

Agency Reports distributed 30 November 2017

Learning Event 7 December 2017

First draft of Overview Report to WSAB 18 January 2018

Recall Event 25 January 2018

Second draft of Overview Report to WSAB 1 February 2018

Presentation to WSAB February 2018

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Appendix Two Swiss Cheese Model20

illustration 1 When the defences provide layers of protection.

Illustration 2: When all layers of defences fail and harm occurs

20 Anatomy of an Error available at http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html

Application of Mental Capacity Act

Understanding Self Neglect

Robust Assessment of Care and Support needs

Robust discharge planning

Limited use and understanding of Mental Capacity Act

Good Practice in working with Self Neglect not applied

Limited Review of Care and Support needs and financial contribution

Robust discharge planning not in place

Application of Safeguarding Procedures

Failure of robust Safeguarding Procedures

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