From April 2015, the Care Act introduced a new statutory duty to undertake safeguarding adult reviews (Section 44). This section contains safeguarding adult reviews undertaken by the HSAB and provides a summary of each case together with professional learning points.
Hampshire Safeguarding Adults
Safeguarding Adult Review Report for Sasha
Statement from the HSAB Chair
The Hampshire Safeguarding Adults Board (HSAB) has today published an independent Safeguarding Adults Review (SAR) into the circumstances surrounding the death in 2017 of Sasha, a young adult.
Firstly, the HSAB would like to express sincere condolences to Sasha’s family for their tragic loss. The family has been involved throughout the review process and it is at their specific request that we have used Sasha’s real name. The Family were invited to provide a statement to accompany publication of the final report and this can be found at the end of this brief statement.
The circumstances of Sasha’s death and her history of contact with a wide range of agencies, gave rise to serious concerns. In response, the HSAB commissioned an independently led Safeguarding Adult Review to establish any learning about the way in which local professionals and agencies worked together to safeguard Sasha. As well as highlighting some good practice, the SAR also identified important learning and key areas for further improvement. HSAB accepts in full the recommendations in the report and we will now be working with partner agencies to share and embed this learning within respective organisations and to deliver improvements in the key areas identified in the recommendations. We expect the learning from this SAR to bring about positive change and improvements in:
- Management of cross border working.
- Transition pathways to ensure these are person centred and provide clear transition plans.
- Early recognition and diagnosis of Autism Spectrum disorders to ensure right approaches and treatment.
- Protocols for managing people who access services on a frequent basis.
- Use of multi-agency risk panels to share information to inform the formulation of multi-agency plans to help mitigate identified risks.
- Guidance to support professionals with understanding advanced decisions and high risk and complex cases that they do not face very often.
- Understanding and application of the Mental Health Act and the Mental Capacity Act where a person is presenting with severe self-harm and suicide behaviour and is refusing treatment.
Mr C (Hampshire)
Hampshire Safeguarding Adults Board
Learning Summary following the Mr C SAR and the Thematic Review of Learning from SARs related to Learning Disability and Physical Health Care
The Hampshire Safeguarding Adults Board undertook a Safeguarding Adult Review regarding Mr C. Mr C had complex care and support needs and was being supported by a number of agencies. Mr C experienced a series of placement moves which had an impact on his emotional wellbeing resulting in a deterioration of behaviour. He stopped eating and drinking which led to a decline in his physical health. Concerns were expressed by Mr C’s care team that there may be an underlying physical cause for him not eating and drinking and losing weight. He was admitted to the local acute hospital trust for observations and diagnostic tests. Mr C was discharged 7 weeks later as it was felt that his condition was due to behavioural and not physical causes. Mr C was discharged to a nursing home in a poor physical state where he received end of life care and he died four days later.
Following Mr C’s death, concerns were raised about his care whilst in hospital, specifically that during his admission, he had not received the necessary tests to rule out a physical health condition as a root cause of his physical presentation. There were also concerns that he was transferred to a nursing home apparently at the end of life when this was not known to those that were receiving him into their care or the community learning disability team.
In addition to the Mr C SAR, the Hampshire Safeguarding Adults Board simultaneously commissioned a thematic review to examine this case alongside two previous SARs carried out under similar circumstances – Mr A (June 2013) and Ms B (Dec 2015). In all three cases, the adults had a learning disability and there were concerns about how their deteriorating physical health was managed. In each case, the death had been premature and unexpected. This raised questions about the effectiveness and embedding of the learning from the previous two SARs and so HSAB undertook a thematic review to identify progress in implementing learning from the previous cases. The Thematic Review also provided an opportunity to explore the blocks and barriers to embedding of learning and solutions to these.
Common issues identified across all three cases include:
- Understanding and application of the Mental Capacity Act.
- Access to advocacy.
- Effective management of transitions in placements and transfer to acute hospital care.
- Involving family in treatment decisions.
- Availability and access to the Learning Disability Liaison Nursing Service.
- Effective hospital discharge planning.
- Use of the Hospital passport.
- Continued use of the Care Programme Approach during hospital admission.
The learning from both the Mr C SAR and the Thematic Review is outlined below. HSAB has produced a multi-agency action plan designed to drive the improvements identified in the review recommendations:
1. Understanding and application of the Mental Capacity Act 2005 (MCA)
All local agencies to:
- Adopt the national MCA Competency Framework and to review organisational training plans and provision against this.
- Adopt the refreshed Hampshire MCA toolkit as one tool for use across Hampshire.
- Introduction of agency executive MCA leads.
- Introduction of MCA champions in all service delivery areas.
- Ensure managers use supervision to support and assess competency and confidence of staff in application of MCA.
- Ensure staff can access guidance on eligibility and entitlement to advocacy support.
- Develop and support a culture of professional curiosity which enables professionals to explore and understand what is happening within an environment rather than making assumptions or accepting things at face value.
2. Communication and coordination
Health partners to:
- Agree a joint protocol for continuance of CPA when a person with a Learning Disability is admitted to hospital.
- Use the multi-agency Risk Management Framework to improve coordination and communication where patients who are admitted to hospital are not subject to CPA.
- Map current provision regarding the learning disability liaison nursing service.
- Introduce Learning Disability champions within hospital wards and departments.
3. Hospital passport
Health partners to:
- Review and develop the hospital passport to address the issues highlighted in the reviews and to include a persons wishes on who they want involved in their care, treatment, environment and discharge.
4. Discharge Planning
Health partners to:
- Review hospital discharges processes and revise to reflect learning from the reviews.
- Ensure care providers are advised of any change in clinical condition that occurs between the initial assessment and actual discharge date.
Local partners, led by Adults Health and Care to:
- Produce guidance on transitions/placement moves that sets out responsibilities of commissioners and providers as well as key agencies.
6. Escalation and challenge
- Professionals should feel able to challenge care and treatment decisions when it is felt these are not in the best interests of the service user and where necessary, escalate concerns to senior managers for resolution. HSAB has developed a multi-agency protocol to support this practice.
Ms B was a 46 year old woman who had a mild learning disability, personality disorder and epilepsy. She was a Portsmouth City Council client who lived in a residential home in Hampshire. She was born on 05/03/68 and died on 12/09/14 at Queen Alexandra Hospital. In this case Ms B’s care and support in the last weeks of her life had involved a complex mix of physical and mental health and care services. Her behaviour had changed significantly and different approaches to respond to this were attempted, but with limited success. Finally her physical health required her admission to hospital and was found to have deteriorated so substantially that little effective treatment was possible. This sequence of events was thought to bring Ms B’s case within the requirements of s44 of the Care Act 2014 as it was appropriate to examine more closely how well the partner agencies and systems in place had worked in responding to Ms B’s needs