Learning from Experience Database - Serious Case Reviews

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A2 (Birmingham)

A2 died in April 2012, in an inpatient palliative care unit for people in the final stages of illness. The cause of death was recorded as dementia, peripheral arterial disease and type 2 diabetes. Since an admission to hospital on 1st November 2011, an end of life pathway had been pursued, keeping A2 comfortable. He was cared for in a nursing home prior to the admission to the palliative care unit and was in receipt of continuing health care funding. A2 also suffered from mental ill health with a diagnosis of paraphrenia and it was at times unclear as to whether he understood the implications of his failure to engage with either health or social care professionals. In November 2011 he was also diagnosed with dementia. A2 was reluctant to engage with professionals despite considerable health needs as well as care needs and safeguarding issues which he alternately acknowledged and denied. His frequent failure to turn up for appointments and declining of support meant that agencies were challenged in their attempts to support him.

Professional Learning:

  • The need for professional to understand the basis upon which service users may decline to work with professionals.
  • The importance of exploring service user’s ability to make judgements about declining health and social care support.
  • The importance of timely mental capacity assessment and use of Independent Mental Capacity Advocates to support best interest decision making.
  • Consideration of a range of legal alternatives associated with the risks inherent in A2’s situation. Professionals should be aware of and/or have easy access to advice on those alternatives.
  • The importance of a holistic assessment informing discussion of the relative role of the two pieces of associated legislation.

2012 September SCR regarding A2 (Birmingham)