Learning from Experience Database - Serious Case Reviews

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JK (Cornwall)

JK was discovered dead in her home on 12.11.08 by members of the Rapid Assessment Team (RAT). JK suffered from a range of health needs but was able to mobilise inside her home using a zimmer frame. She was assessed as able to manage her own personal care and meals and relied on friends to undertake her shopping. However she chose not to go outside her property, and was known to spend the main part of her day on her bed with her three dogs. It is reported that there were no concerns that she lacked mental capacity and her decisions to lead this lifestyle. In the years before her death there were a number of reports regarding the poor state of hygiene in the house and the presence of dog faeces on the floor. A number of agencies were involved with JK in the week immediately prior to her death.

Professional learning:

  • Assessments and care plans should have a service user focus rather than reflect the available service and interventions.
  • Assessments and care plans should address issues of reluctance to engage with services.
  • Multi- disciplinary meetings (as part of business as usual) should be held when there are concerns about a vulnerable adult.  A key worker should be identified to co-ordinate the shared plan.
  • Thresholds to indicate when circumstances of self-neglect tip into safeguarding.
  • Clear and robust record keeping of decisions and actions taken.
  • Feedback provided to referrers on outcomes and actions following alerts/referrals.
  • Monitoring of how often service user refusal to accept services to detect repeating and escalating patterns.
  • Guidance should be provided for practitioners on approaches to working with vulnerable people who refuse services and/or at risk of self-neglect.   

2009 June Serious Case Review regarding JK (Cornwall)