Learning from Experience Database - Serious Case Reviews

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D (Kent)

This case concerned a young man (D) who had profound physical and learning disabilities. He died in hospital, aged 27, from uncontrolled fitting exacerbated by other serious conditions. He had lived with his parents in impoverished and squalid surroundings. For much of the period reviewed, failure to act within a Child Protection framework was a significant factor in his ongoing experiences of inadequate care and serious neglect. It has raised questions about the way in which protection issues are managed within a transition planning process as Social Services did not interpret diffuse actions or failures to act as indications of continuing neglect and deprivation, which would have warranted definitive action. Health care professionals were confused about where the responsibility for decision-making lay and did not challenge actions which ran counter to D’s best interests. It is unclear whether the failure of his parents to seek out or comply with medical treatment contributed to his early death.

Professional learning:

  • Previous history of any safeguarding concerns should be passed to the GP to assist in diagnosis, treatment and discharge.
  • Child protection or child in need concerns should be central to the transition planning process.
  • A vulnerable adult is the primary client who should be at the heart of the protection process; legal action should actively uphold the vulnerable person’s human rights.
  • Medical, nursing and care management staff must be aware of best interest decision making and about the role of families and the formal decision maker.
  • Staff should be fully aware of the relevant parts of the Mental Health Act and Mental Capacity Legislation. In individual cases they should be fully briefed through the multi-agency arrangements to assist in professional decision making.
  • Safeguarding concerns must be taken into account in discharge planning from hospital settings.
  • Police need to be clear about responsibilities to use common, civil or criminal law to achieve safe outcomes for adults and children.
  • Staff must be fully cognisant of their powers and duties under a raft of legislation and avenues to achieve a safe outcome.
  • Staff should receive training in managing difficult personal interactions and in dealing with confrontation and conflict.
  • In extreme cases there should be contingency funds available so it is possible to seek additional legal or professional advice to support the safeguarding process.

2003 Serious Case Review regarding D (Kent)