Learning from Experience Database - Serious Case Reviews

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Mr J (Kent)

Mr J was a fifty-nine year old vulnerable adult living in supported temporary housing after a period of homelessness following the breakdown of his marriage. In May 2008 he saw his GP and reported that his memory had deteriorated dramatically and that he used to have an alcohol problem. He was referred to mental health services where it was found that he had Alzheimer’s disease. Mr J was treated with medication and monitored. It emerged during 2008 that Mr J was experiencing difficulties with other residents at the supported housing and their associates. These people were variously said to be prostitutes and drug users. There were reports of thefts from Mr J which were investigated by police. Mr J would not agree to criminal charges being brought. It was judged that Mr J was able to live more independently and he moved on from the temporary accommodation he was in and he moved to alternative accommodation. In early 2009 police became aware of concerns he was still being exploited by acquaintances he had met at his previous accommodation. Police were involved in criminal investigations when Mr J made allegations against these people but he subsequently withdrew the allegations or they could not be substantiated. He was seen twice in the Accident & Emergency Department with facial injuries, which he insisted had been caused accidentally. Mr J was subject to a safeguarding referral which resulted in him moving to a care home on a temporary basis as a place of safety. After a short period, Mr J moved back to his own home. Monitoring visits found Mr J not be coping well. There were indications of excessive drinking, disorientation and inability to manage personal care needs. Two weeks after returning home, Mr J was taken to hospital where he was found to have multiple cuts, bruises and possible pressure sores of varying ages, and to be extremely dehydrated. He had multiple injuries to his brain. He deteriorated further and died in hospital four days later.

Professional learning:

  • The importance of relationship building with difficult to engage people or those at risk of exploitation.
  • The importance of addressing isolation and supporting service users to strengthen or re-establish family/social networks as a means of protecting from further harm/exploitation.
  • The importance of involving the GP and also having a GP when leaving residential care.
  • There was no process of care planning, assessment and review.
  • Input from professionals lacked direction and purpose, and was not alert to the safeguarding dimension of the situation.
  • The need for clear and robust risk management and understanding as to the threshold for referring issues into the safeguarding procedures.
  • There was a confused approach to the implementation of safeguarding arrangements once it became clear that Mr J was being exploited and abused. There was a lack of compliance across agencies with basic safeguarding procedures relating to the notification, recording and follow up of safeguarding concerns.

2013 June Serious Case Review regarding Mr J (Kent)