Learning from Experience Database - Serious Case Reviews

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Mr A (Southampton)

Mr A was a 49 year old man who had a mild to moderate learning disability as well as epilepsy and scoliosis. He had lived in supported accommodation since his early twenties and in December 2006 he moved to supported living provided by Wessex Regional Care Ltd a service which provided tenancies domiciliary support to people with learning disabilities. In the last three months of his life Mr A became physically ill and suffered from recurring stomach complaints. He was also adversely affected by the level of disturbance within ‘the flats’ caused by both the nature and mix of the residents. In the last week of his life Mr A had continued stomach problems which were not adequately dealt with. On Monday 20 December Mr A died from natural causes, defined by the coroner as a combination of dehydration, colitis and epilepsy. The SCR was established to investigate how death could have occurred in a supporting living establishment with staff available 24 hours a day. It concluded that Mr A’s death was preventable. The cause of Mr A’s death was systemic. A group of contributory factors combined to create a situation where a vulnerable adult was allowed to die in circumstances where he was living in supported accommodation. The Coroner in his narrative report came to the conclusion that Mr A’s death had been “preventable and unnecessary” and “that the systems in place to deal with Mr A’s health generally were inadequate and insufficiently robust”.

Professional learning:

  • If safeguarding concerns involve more than one vulnerable adult, meetings must give equal attention to each and assess respective needs/risks and the inter-relationship of these.
  • Monitoring of contracts should include initial monitoring of the level of support needed, confirmation that the care plan reflects identified needs; ongoing review of the level of support offered; quarterly checking of the records showing how that support has been provided and outcomes; spot checks of the property.
  • Providers should record a summary of their assessment, advice or the outcome of their visit in the service user’s ongoing record.
  • Visiting professionals who have concerns about the standard of care and/or the general state of the environment should raise concerns with the senior member of staff on duty; request details of the provider organisation and the commissioning organisation; be aware of their professional code of practice to highlight any sub-standard care.
  • Clear policies and practice guidance disengagement/refusal of support should be available. A protocol and thresholds should be agreed locally as to when incidents of refusal are escalated internally and out to care management teams.
  • Commissioners should assure themselves that provider staff have the necessary knowledge and competence re MCA practice.
  • Protocols must be in place in provider services about informing relatives of a family member’s illness so that they can be involved in decision-making around the service user’s care.
  • Police and anti-social behaviour teams should monitor frequent incidents/call
  • outs to the same address (particularly where it is a multiple occupancy).
  • Thresholds should be in place as to when to make a safeguarding referral.

2012 July Serious Case Review regarding Mr A (Southampton)