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Learning from Experience Database - Serious Case Reviews

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Mr I – Wokingham

Mr I had suffered a brain injury and had a lower leg amputation. He was prone to depression and developed an increasingly severe dependence on alcohol. He resented contact from the services and was aggressive to visitors including the regular care staff who had been commissioned by the Local Authority to provide daily support and monitoring. His case was transferred from the Local Authority Long Term Team (LTT) to the Mental Health Review and Reablement (R&R) Team in June 2013, but despite their best efforts the new keyworkers struggled to develop a working relationship with him. Mr I was assessed as having the mental capacity to make decisions about his health and welfare. The keyworkers took his case to the Risk Enablement Panel (REP) in April 2014 hoping that the case would be transferred, however the REP instead encouraged them to continue with their attempts to engage Mr I. However no meaningful work was possible due to Mr I’s use of alcohol and reluctance to engage, and so it proved very difficult to reduce the risks involved.

The daily carers continued to call but often did not manage to see Mr I, so the police would occasionally be asked to undertake welfare checks. In July 2014 it was agreed by the workers and managers of both teams that the case should be transferred back to the LTT and held on duty (as opposed to being allocated), however due to other work pressures the mental health keyworker did not progress the transfer. In April 2015 the keyworker took the case back to the REP who agreed that the decision to transfer the case back to the LTT should be progressed. However the usual procedures for handover recording and case transfer on the health and the Local Authority IT systems were not completed correctly by the R&R team.

At this time a significant re-structure of the Local Authority teams resulted in the LTT duty function being provided by the Single Point of Access (SPOA) team. A period of confusion and increasing frustration between teams followed. The case began to be managed by the SPOA but they had no access to the recent mental health records and the transfer had not been formally confirmed. This led to a lack of clear accountability for the case. During this period the teams were unaware that Mr I’s physical health was significantly deteriorating. He died unexpectedly in June 2015 and was found in his home several days later by the police.

Details here:

icn_pdf MR I Final Report 2016