Learning from Experience Database - Serious Case Reviews

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A1 (Worcestershire)

At the time of his death A1 had been known to local mental health services since at least 2002 and had been treated for depression, anxiety, and behavioural problems. There had been a diagnosis of paranoid schizophrenia earlier in his clinical history. He also suffered from chronic gastric problems and was well known to his General Practitioner. A1 rented a housing association bungalow in Evesham but had been living with his 88 year old mother for nearly a year before his death. A1’s mother was admitted to hospital in late December 2008 and following a multi-agency safeguarding meeting it was agreed with A1’s family that he should return to his own bungalow before his mother’s discharge from hospital. This meeting had been held under local safeguarding procedures owing to the mother’s vulnerability and concerns having been raised about A1’s behaviour and its impact on his mother.  A1 was visited at his bungalow by the local Community Mental Health Team following the move and was also assessed for home treatment. He was considered to have sufficient mental capacity to live independently. He was last visited at home by a number of health professionals before his death but then missed a number of subsequently routine out-patient appointments. Neighbours and a utility service worker became concerned and A1’s body was discovered at home by the Police on 25th March 2009. The cause of death was later recorded by the Coroner as “pneumonia, paranoid schizophrenia and inanition”.

Professional learning:

  • Policy and practice guidance should clarify and facilitate family involvement and information sharing so that the privacy of the individual is not compromised but neither is their vulnerability increased by barriers being placed in the way of open information sharing by family members.
  • Family members, their relationship and role in caring for known patients and clients should be clearly recorded as part of a mental health Standard Care Assessment. Consideration should then be given to whether they need to be proactively contacted by professionals as part of intervention.
  • Any family members identified who are providing care or substantial support should be offered a Carers Assessment.
  • There should be clear thresholds in place to assist in identifying when a multi-agency approach should be used where there are serious concerns but the case falls short of safeguarding procedures. Such cases should have management oversight.
  • Safeguarding training strategies should include provision on managing self-neglect.
  • The LSAB should develop clear links between the Coroner’s office and safeguarding teams.

2010 April Serious Case Review regarding A1 (Worcestershire)