Learning from Experience Database - Serious Case Reviews

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MM (Essex)

MM was an 89 year old lady living in her own home with a good network of support from her local church. She was estranged from her daughter. MM also had an adult son with cerebral palsy and mental health issues living independently. She had a strong dislike of anyone associated with Social Services since she believed they were responsible for ‘removing’ her son from her home when he moved to live independently in 2004. As a result of concerns about her husband’s care in hospital prior to his death in 2006 MM was also resistant to hospital admission. MM was often described as difficult or cantankerous by those who had involvement with her.  She had deteriorating health between January 2009 and May 2012. However, consistency refused care. Following significant deterioration in her condition and mental capacity, MM was admitted to hospital where staff recorded her in a foetal position covered from neck to toe in faeces and urine. MM’s hair was also noted as matted. Noted as having ground in faeces, reported as soaked but still staining the skin. MM continued to deteriorate and died on 6th May 2012.

Professional learning:

  • The need for clear guidance on managing self-neglect in the context of mental capacity and best interests.
  • Better understanding of the role of the Mental Capacity Act by agencies, particularly GPs. Specifically with this case there had been confusion between the applicability of Mental Capacity Act and the Mental Health Act.

2012 Serious Case Review regarding MM (Essex)