Learning from Experience Database - Serious Case Reviews

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JT (Dorset)

Mrs JT died on 29 May 2012 as a result of a stroke. She had, in January 2012, been admitted to a care home. This was an emergency measure because her husband, who was her main carer, had suffered a stroke and was admitted to hospital. In March 2012 JT transferred to a nursing home, where she died.  JT’s general condition and health on admission to the care home in January 2012 gave rise to significant concerns as a result of which a safeguarding alert was raised and an investigation ensued. This subsequently gave rise to questions about the way in which local professionals and services had worked together in this situation. JT was an adult at risk known to a range of health and social care agencies. She had a range of health related conditions which rendered her increasingly dependent and isolated. JT was, for her own reasons, at times reluctant to accept care and treatment offered by professionals. This should have been explored with her by staff and professionals. This reluctance, combined with the increase in health and care needs was challenging to the effective management of risk. The situation demanded basic good practice, a high level of continuity and communication across agencies as well as an ability to keep track of a situation, which continued over two decades, in order to ensure that needs and risks were adequately addressed. A number of failings combined in this situation leading to agencies and professionals failing to recognise, acknowledge and address the serious level of deterioration in JT’s condition

Professional learning:

  • The need for a clear framework for the identification, assessment and management of risk across agencies including a focus on working with those who are reluctant to engage with services and treatment.
  • Improvements in monitoring practice in relation to the Mental Capacity Act.
  • Implementation of best practice in working with stroke illness.
  • Improved practice in working alongside carers and in carrying out carers’ assessments
  • Better understanding of the relationship between pressure ulcer care and safeguarding adults.
  • Ensuring robust practice in relation to Do Not Attempt Cardio Pulmonary Resuscitation (DNAR).

2012 May Serious Case Review regarding JT (Dorset)