Learning from Experience Database - Serious Case Reviews

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DD (Slough)

DD first became known to Adult Social Care in December 2007 when, following an admission to hospital, she was referred by a GP for social care assessment. This assessment concluded DD was managing relatively independently with low level input from Age Concern; family members and assistance with housework funded and arranged privately. There were further concerns in late 2008 and in the first half of 2009 relating to DD’s ability to manage independently and references in particular to her memory and a level of confusion. There were concerns about safety in relation to DD’s use of the gas cooker and an incident where she had locked herself out. She was in receipt of a meals service. Following a fall in November 2009 DD was again admitted to hospital and following discharge a package of care was arranged including three calls daily to assist with daily living tasks. DD continued to receive care from the care agency from this point until her death in May 2012. DD was referred to the Community Mental Health Team for Older People in January 2010. The GP was also involved during this time, including responding to calls from family and from carers from the care agency. Following her discharge from hospital in May 2012, DD died in circumstances which gave rise to significant concerns about the way in which local professionals and services had worked together in this situation.

Professional learning:

  • The importance of a robust multiagency approach to achieve a holistic overview of needs and risks.
  • The importance of clear recording with the rationale for actions and decisions taken clearly documented.
  • The importance of statutory agencies both seeking out information from front line carers to inform assessment, monitoring and review processes and sharing information with them.
  • The lack of a person centred approach can impact significantly on the quality of intervention.
  • The importance of offering a carer assessment.
  • The importance of robust risk assessment and risk management and the need to coordinate information and decision making around the known risks.
  • The importance of engaging the service and family members in the risk management process and plan.
  • Recognition that robust recording is an essential part of practice especially in circumstances of risk and the value of standard recording formats in key areas such as risk; safeguarding adults; mental capacity assessments.
  • Recognition that responses to self neglect/refusal of support have to be considered in the context of the person’s mental capacity.
  • Failure to carry out a timely assessment to ascertain a diagnosis of dementia contributed to an absence of personalised care, any clear strategy to manage risks and plans and contingencies to optimise care.

2012 May SCR regarding DD (Slough)