Learning from Experience Database - Serious Case Reviews

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Adult X (Worcestershire)

X was well known to local services for many years. During the period under review he lived at home with his mother, step-father and three half-brothers. He was born with severe learning disabilities. Throughout his life he was unable to talk or care for himself and he suffered from epilepsy. X continued to require residential and day care as he became an adult. The care package agreed for him included day care and respite care. During the second half of 2007, X ceased attending one of his day care and by November 2007 his attendance at his second placement had reduced. In addition, staff were concerned at his apparent weight loss and these were eventually reported to the Learning Disability Team. On December 19th 2007 these concerns were formally reported to a senior member of the Learning Disability Team. No action was taken by the Team until January when phone calls were made to his mother who was X’s main carer. She assured that X would be taking up his place again. In the event X did not attend again. On March 19th 2008 Team made a visit to X’s home but again was unable to see him. This was followed by a further visit on April 4th at which the worker spoke to X’s mother. Subsequent efforts were made to establish X’s condition and whereabouts. On April 23rd 2008 X’s body was discovered in the back garden of the family home. He had been dead for some time. This followed the discovery of the body of X’s mother on April 21st elsewhere.

Professional learning:

  • Concerns or anxieties about a vulnerable adult should be reported immediately however ‘low level’ or uncertain.
  • Those responsible for action under Safeguarding Procedures must make an adequate and rigorous assessment of reported concerns within agreed timescales. Recording of meeitngs and actions taken should be robust.
  • Care should be well co-ordinated based upon effective assessment and reviewed annually.
  • Carers must be informed of their right to a carers’ assessment.

2008 December Serious Case Review regarding Adult X (Worcestershire)