Learning Tgether Frm Safeguarding Adult Reviews Key findings and learning utcmes frm the recent Safeguarding Adult Review cncerning Adult A Adult A: The East Sussex Safeguarding Adults Bard (SAB) recently published the findings f a Safeguarding Adult Review (SAR), which evaluates multi-agency respnses t the death f a man aged 64 (Adult A), frm Kent, wh was living in a care hme with nursing in East Sussex, cmmissined by NHS West Kent Clinical Cmmissining Grup (CCG). Adult A died as a result f systemic sepsis, infectin f his legs, diabetes and cirrhsis. He was subject t Deprivatin f Liberty (DL) in his best interests as he was deemed t lack mental capacity t decide where t live. There were cncerns f self-neglect as he ften refused care and treatment. Sharing learning is a key pririty f the East Sussex SAB. This includes develping strategic learning acrss agencies, bards and brders, learning frm natinal best practice and Safeguarding Adult Reviews (SAR). This shrt briefing summarises the key findings and recmmendatins frm the SAR. All staff and managers are encuraged t discuss this briefing and the key learning and reflectin pints at the end f the briefing, t ensure that the learning utcmes are used t cnslidate existing best practice and make imprvements where required. If yu wrk with vulnerable adults in East Sussex, there may be additinal specific actins and recmmendatins fr yur agency and yur rle. Yu can als read the full reprt n the SAB website. The Review: The SAR was led by independent reviewers Suzy Braye and Michael Prestn-Sht and examined the fllwing areas: 1. Hw care placements were rganised and reviewed; 2. Hw health and scial care prfessinals wrked tgether acrss gegraphical brders; 3. Hw Adult A was engaged with; 4. Hw Mental Capacity and Deprivatin f Liberty were assessed; 5. Hw the interface between the Mental Capacity Act (MCA) and the Mental Health Act (MHA) were understd and applied by prfessinals and, 6. Hw care and treatment plans were agreed and fllwed. The review cvered the perid f 25 th August 2015 frm Mr A s admissin t Maidstne hspital, until his death in the nursing hme n 24 th July 2016. 23 recmmendatins were accepted by the SAB fllwing the review, and a jint actin plan with the Kent & Medway SAB is nw in place t ensure learning utcmes are achieved and t try and avid similar cases ccurring again in the future. The recmmendatins and the actin plan can be fund nline alng with the reprt. The East Sussex SAB is cmmitted t taking the learning frward t safeguard adults, and hpes the findings will infrm plicies and practices elsewhere in the UK.
Key findings: Finding 1: Placement Difficulties finding smewhere where Mr A s care and treatment culd be managed started well befre the perid under review, while Mr A was living in Kent. The review identified a shrtfall f placements suitable fr peple, like Mr A, wh have highly cmplex needs. The SAR recmmended that the SAB: Prmtes the develpment f a database f specialist placements capable f managing peple with cmplex needs and challenging frms f behaviur. Prmtes wrk between relevant CCGs t address the cmmissining/market shaping gap regarding services fr peple with cmplex needs and challenging frms f behaviur. Seeks reassurance that cmmissining prcesses are rbust in identifying the degree t which recmmended placements have the capacity and resurces t meet an individual s identified care and supprt needs. Finding 2: Case Crdinatin and inter-agency cmmunicatin The unsuitable nature f the placement was cmpunded by a lack f practive fllw up by NHS West Kent CCG, and a resultant failure f case crdinatin. Challenges f wrking acrss brders and therefre at a distance may have added t the difficulties. On n ccasin did all relevant agencies and prfessinals cme tgether t agree a plan t intervene in Mr A s best interests. Withut strng leadership acrss the system, the effrts that individual agencies made t secure care and treatment fr Mr A tk place in islatin. The SAR recmmendatins included that the SAB: Seeks reassurance regarding systems in place fr ntificatin and mnitring f ut f cunty placements bth where East Sussex is the placing rganisatin and the receiving rganisatin. Undertakes an audit f ut f cunty placements t evaluate whether there are systemic patterns t be addressed. Reviews cmplex case prcedures t ensure that all agencies are aware f prcedures fr multi-agency reviews f cmplex cases, with particular reference t ensuring that: all available infrmatin is shared acrss the agencies invlved, all agencies have access t advice and guidance frm legal practitiners, all agencies agree and fllw thrugh n a multi-agency actin plan. Fr all care and nursing hme residents, prmtes the use f ne shared recrd held at the care hme by all prfessinals invlved, t ensure that all practitiners are aware when visiting a resident f the key issues within the chrnlgy f the case. Establishes a task and finish grup t review recrd-keeping and infrmatin-sharing between agencies; t make prpsals regarding the transfer f infrmatin, including reference t hspital discharge planning and admissins t care hmes, and cmplex cases invlving cncerns abut self-neglect and mental capacity.
Finding 3: Mental Capacity At mst pints at which capacity was assessed, Mr A was fund t lack capacity t make decisins relating t his living situatin, his care and treatment. One such assessment by a dctr at Maidstne Hspital resulted in a decisin t place him in a nursing hme in East Sussex. A decisin was subsequently made t authrise the deprivatin f his liberty t ensure that he remained there. Paradxically, Mr A s refusal f care and treatment n a daily basis in the nursing hme was respected by staff, and endrsed at a best interests meeting in January 2016. Best interests interventins using the prtectins f the Mental Capacity Act were nt actively pursued, and n cnsideratin was given t referring Mr A s case t the Curt f Prtectin, when such a referral wuld have been entirely apprpriate at varius pints during the final six mnths f his life. The SAR recmmendatins included that the SAB: Reviews the effectiveness f training in raising awareness and strengthening knwledge with respect t the Mental Capacity Act 2005, referrals t the Office f the Public Guardian and the Curt f Prtectin. Cnducts an audit f cases t evaluate the utcmes f best interests decisin-making, with particular reference t assessing multi-agency invlvement and clarity abut leadership respnsibility. Reviews guidance n mental capacity assessment t include a prcess fr securing multidisciplinary capacity assessment in cmplex cases where multidisciplinary teams are respnsible fr decisin-making. Reviews guidance fr staff n wrking with thse hlding LPA. Finding 4: Interface between mental capacity, mental health and physical health There were missed pprtunities t engage practively with Mr A s mental health, despite the recgnitin that it affected his ability t allw thers t care fr him. N cmmunity mental health referral was made at the time f his discharge frm Hspital, and n referral was made during the early mnths f his hme placement, nr fllwing the best interests meeting in January 2016. Despite advice frm a cnsultant psychiatrist that assessment culd be cnsidered f whether Mr A met the grunds fr hspital admissin under the Mental Health Act 1983 (which culd have facilitated his physical treatment), n such assessment tk place. This was nt practively fllwed up by the nursing hme, GP r the psychiatrist. This was a significant missin as the impact f his mental health as a ptential underlying cause f his refusal f care and treatment was nt tested. The interface between physical health, mental health and mental capacity is cmplex, and required mre explicit interagency discussin than it received in Mr A s case. The SAR recmmended that the SAB: Reviews guidance n legal ptins fr intervening in self-neglect, with and withut capacity, t include cnsideratin f the interface between the Mental Health Act 1983 and the Mental Capacity Act 2005, and the use f the Curt f Prtectin and f inherent jurisdictin. Reviews with cmmissiners and prviders f advcacy services (including PRPRs and IMCAs) measures t address shrtfall in the number f available advcates, and mnitrs further develpments in advcacy prvisin.
Finding 5: Safeguarding The review shwed that safeguarding prcesses were nt effectively used in Mr A s case. A safeguarding referral was nt made until the weekend he died, whereas safeguarding referrals culd and shuld have been made at numerus earlier pints by any f the peple invlved in his care and treatment. The SAR recmmended that the SAB: Prduces briefings t prmte and refresh safeguarding literacy in the cntext f the Care Act 2014, with particular reference t the referral pathways and threshlds fr sectin 42 safeguarding enquiries and the use f cmplex case prcedures and multi-agency meetings in challenging cases, as well as awareness f, and cnfidence in, understanding factrs cntributing t self-neglect. Seeks reassurance that practitiners and managers acrss agencies understand and use pathways fr seeking advice frm, and escalating cncerns t, safeguarding leads within their wn rganisatin, and are able t use safeguarding referral pathways apprpriately... Finding 6: Invlvement Althugh Mr A was placed in a lcatin t which he and his attrney were ppsed, his cnsistent refusal f interventin was respected, despite the view that he lacked capacity t make that decisin. Instead f being ne f a number f factrs t be taken int accunt in determining his best interests, his wishes were allwed t determine the actins that prfessinals tk (r mitted t take). T cmply with best interests decisin-making requirements, a mre nuanced balance f a range f factrs, including the risk t his life, was required. The persn wh held Lasting Pwer f Attrney (LPA) n behalf f Mr A was knwn t find this rle difficult, bth because f the distance t Mr A s placement and because she was struggling anyway t make decisins in his best interests. Nt all agencies were aware f her existence. N cnsideratin appears t have been given t whether her difficulties shuld have been ntified t the Office f the Public Guardian, which has respnsibility fr verseeing the wrk f thse hlding LPA. The SAR recmmendatins with regard t this area are cvered under Findings 3 and 4 abve.
Key pints fr learning and reflectin D yu knw wh t reprt t r seek advice frm if yu have a safeguarding cncern abut an adult yu are wrking with? D yu knw hw t escalate a cncern? Are yu familiar with the arrangements in yur service fr sharing infrmatin with ther agencies? D yu understand hw the Mental Health Act and the Mental Capacity Act can be used t ensure that adults with mental health needs can get the treatment they need? D yu knw hw and when yu can refer t the Curt f Prtectin? Managers are encuraged t explre the learning pints abve in team meetings and supervisin. Further training in relatin t safeguarding and the Mental Capacity Act is available at the East Sussex Learning Prtal If yu require any further infrmatin abut the SAR and actin plan please cntact: Fraser Cper, SAB Develpment Manager - fraser.cper@eastsussex.gcsx.gv.uk