KA
| Date of SAR | 13 April 2018 |
| SAR Reviewer | Mick Hagger & Eliot Sullivan-Smith |
| Owner | LB Hounslow - Monuara Ullah |
Executive Summary
List of Contents
1. Introduction
2. Summary of Events
3. Analysis of Case
4. General Conclusion
5. Recommendations (Findings 1, 2, 3 & 4)
1 INTRODUCTION
In October 2016, KA died alone in his flat in Hounslow. KA had a number of serious health issues, including type 2 diabetes, chronic back pain and earlier in the year he had a heart bypass. KA also had long-standing mental health problems but did not accept treatment for these. KA was supported at home by a package of care provided by the Local Authority, primarily to assist him with his prescribed medication regime; KA was known to misuse his medication, taking high quantities of his pain relief, and sleeping medication. He was known to present regularly to hospital, where his needs were assessed, and his care arranged. KA died from heart failure and concerns were identified about the multi-agency response to a series of “No Replies” to Home Carer visits over his final weekend.
The Hounslow Safeguarding Adult Board considered the case known as KA in January 2017 and decided that it met the criteria for a Safeguarding Adult Review as set out in the Care Act 2014. The case offered much useful learning about systemic issues related to how primary health care, hospital adult social care and mental health services work together with community-based services. The case highlights the challenges of capacitated adults who may be at risk of severe self-neglect in the community and frequently present to hospital services.
The Safeguarding Adult Board selected the SCIE Learning Together systems model (Fish, et al., 2009). The following research question was set:
How effectively are front line practitioners supported to make urgent decisions for high- risk clients in a crisis, and how well do services share information about management of risk with EDT?
A Learning Together review process has at its heart, three key principles, these are known as the ‘methodological heart’:
1. Avoid hindsight bias – understand what it was like for workers and managers who were working with the family at the time. In particular, explore what sense they were making of the case, and the contributory factors which were influencing their practice at the time
2. Provide adequate explanations – appraise and explain decisions, actions and inactions in professional handling of the case. See performance as the result of interactions between the context and what the individual brings to it
3. Move from individual instance to the general significance – provide a ‘window on the system’ that illuminates what supports and what hinders the reliability of the multi-agency safeguarding system.
2. SUMMARY OF EVENTS
Initially the focus of this SAR was on the short period of 4 days prior to his death, although this was subsequently extended to include a longer period that began with an admission to hospital in February 2016.
KA did not engage with mental health services and lived a fairly isolated life. He always had a vivid imagination and would invent stories of a grandiose nature. KA smoked heavily and drank litres of cola a day, despite being diagnosed with diabetes. He had a reversed sleep cycle whereby he would be up all night, but then sleep during the day. He did not work and did not go out often. He suffered a brain haemorrhage, which was related to his poorly controlled diabetes and his sister identified this as a factor exacerbating his poor mental health. KA never accepted assessment or treatment in the community for his mental health. KA had a heart bypass in February 2016 and had been in diabetic coma when he was brought to hospital. He was found by his friend, who lived in the same block of flats. Until 2016 KA was supported at home by his nephew and two friends who shared the property with him and offered support with cooking and cleaning. KA had a pattern of frequent brief admissions to his local hospital in Hounslow. He regularly called for an ambulance citing acute back pain and upon admission to hospital would request additional pain-killers. He was seen for two assessments of his needs whilst in Hospital by Hospital Based Social Workers during 2016 and was provided with a Home Care Service in July 2016. He was also seen by the Hospital Psychiatric Liaison Services, who met him and then discharged him to the care of his GP.
The home care service was set up for two calls a day to supervise his medication and help him keep his flat in order. The package of care was suspended when he stayed with his sister in August 2016, during which time he slipped and fractured his leg. He returned to Hounslow in September 2016 and his package of care was restarted. Over a weekend in October, he did not reply to five calls from his home carer. Following concerns from First Contact on the Monday, the police broke into his flat and found that KA had died during the weekend.
3 ANALYSIS OF CASE
KA had been living in Hounslow for many years before he came to the attention of statutory services. Until 2016, KA had managed independently, relying on the support of his Grandparents, then other family members and friends. When he could no longer rely on the support of his informal networks, KA became more visible to professionals. While in Hospital, health professionals observed that KA had difficulties in looking after himself, in particular caring for his personal hygiene, mobilisation, and transfers from bed to chair and vice-versa. KA was assessed by the Hospital Social Work Team, and on one occasion was seen by the Hospital Psychiatric Liaison Service.
Due to the frequency of his admissions, KA’s assessment of need – social care, physical health, and mental health, all took place within the acute hospital environment. The assessments were conducted to a contextually high standard, however relied heavily on third party information and service user self-perception, and self-report. This, combined with the care provided to KA by the Hospital prior to his assessments, biased the assessment towards personal aspects of wellbeing, and reduced the visibility of his risk of self-neglect.
KA’s formulation of need was based upon his self-management of his medication regime, which had a significant impact on his sleeping patterns, management of diabetes, and was thought to have contributed to poor cognition and impaired ability to look after himself. A package of care was therefore appropriately commissioned following the assessment around his greatest need – administration of medication, with additional tasks to include meal preparation (managing and maintaining nutrition) and supervision with daily tasks (which may have included maintaining personal hygiene, and managing toilet needs). The Local Authority took on responsibility for a package of care to meet some social care needs, but also heath needs, namely management of medication.
Following his discharge from Hospital, information recorded on the Adult Social Care system was used to commission a care package. The domiciliary care agency received a summary of information but did not have contact with the assessing social worker and they do not receive full assessment information. The care agency was not aware of the severity of KA’s physical health problems nor had a sufficient understanding of the complexity of the case and related risks. Carers were not aware of concerns about KA’s medication self-management and were not attuned to the risk of self-neglect. Carers believed that their commissioners (the Local Authority) were aware of the issues – for example the state of the accommodation, and so did not escalate any concerns they may have had about this.
During the weekend of 14/10/2016 care calls from the Friday to the Sunday were all provided by the same carer. On Friday the 14/10/16 the carer visited KA in the afternoon, when he was there with his friend (who lived in the flat opposite, a frequent visitor to KA). On this occasion, KA was vomiting when the carer arrived. The carer offered to bring him some hot water and to phone an ambulance for him, but KA refused, saying he was OK. The carer did not escalate KA’s incidence of illness. This was the last time KA was seen. Subsequent home visits were all recorded as ‘no replies’, and the case of KA exposed weaknesses in agency on-call systems, pressure on the EDT system, and availability of information about KA to the out of hours service.
This case highlights vulnerabilities in the way that the multi-agency system works together with service users who, because of their fluctuating medical needs, are in and out of hospital. There are examples of individual good practice in this case, but this is a product of a particular person’s ability at a given time rather than an indication that the system is enabling of good practice because of the way it operates. The case is particularly relevant for consideration in the current climate where hospital places are at a premium, with associated pressure to discharge - and Findings highlight various ways in which this context has resulted in a particular culture of practice by way of response.
4 GENERAL CONCLUSION
This SAR highlighted some learning for individual organisations in this area, which has already taken place following the KA case. In particular the Home Care X did identify the need for additional management on-call staff resources after this incident. There are now more on-call agents so there is more time for responding to phone calls; there are on-call agents for each borough that the Home Care X covers. There is also now a database for each out of hours report and any issues arising for the on-call agents. There is a better IT system in place for accessing client information out of hours. This means that where different on-call agents cover weekend days they can easily see whether there had been any previous no replies on preceding days. There are also weekly on-call meetings, where managers can discuss what has happened that week, any issues arising and any improvements, which need to be made. Home Care X had made these changes as their single agency learning from this case and this should assist with better decision making for No-Replies reported out of hours to Home Care X. The systems in place for other Home Care Providers should also be explored to assess current arrangements for out of hours and ensure sufficient staffing is in place for all Hounslow Providers.
Learning had also been taken forward by the Emergency Duty Team, which recommended that the No-Reply policy that they use for work in LB Ealing also be modified and adopted for LB Hounslow, which did not have an equivalent policy or procedure for No Replies. As the Ealing document was viewed as overly complicated, a new version has been adapted for use by EDT for No Replies reported about Hounslow residents out of hours. This specifies the roles and responsibilities for each agency, including the pre-referral checks to be done by the provider with local hospitals and the standard of information required for a referral to EDT. One of the issues identified in this case was when KA was referred via Hounslow call handlers to EDT on Saturday; this referral did not contain sufficient client details to enable this to be followed by the Social Worker on duty that day.
Whilst this SAR recognised that the above learning has taken place, this does not form part of the subsequent 4 Key Findings, which have arisen from the Review. These have been identified as systems issues, which require further consideration by the HSAB.
5 RECOMMENDATIONS
The SCIE approach uses systems-based analysis, which produces Findings and subsequent Questions for the HSAB to consider, rather than recommendations and action plans. This is because the causes of the Findings may be complex and need further exploration by addressing the questions as set out, rather than assumptions that the solutions are simple actions (such as more training, or more supervision).
The case of KA has generated four findings which are summarised briefly here, and in full below.
Finding 1: Does the practice of snap-shot assessments in hospital settings in relation to clients with frequent patterns of hospital admission/discharge, factor
against more longitudinal case oversight and assessment, with potentially dangerous consequences for cases where self-neglect is a recurring issue?
When people go to hospital for a physical health problem, their home situation is often not well known, although concerns about their ability to cope can give rise to a referral for a social work assessment. This is carried out by visiting the person on a hospital ward and taking a brief history. It may be hard to gauge the extent of their difficulties in the community and a thorough assessment is not enabled, due to the pressure of working in hospital settings. Complex patients who are not able to give a clear picture of their needs can lead to these being underestimated when they are only seen in a hospital setting.
Finding 2: The awareness and identification of self-neglect as a deeper underlying issue may be missed, particularly by hospital-based staff who rely on patients self-reports of how they are coping, but do not see their home conditions, or where an assumption is made that services are already aware of an individual’s ‘baseline’ level of functioning.
Self-neglect is defined in the Statutory Guidance accompanying the Care Act 2014.
“This covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case-by-case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support”.
Finding 3: There is no process for review of client data for people with recurrent patterns of admission/discharge, with the consequence that information sharing and discussion across different professional disciplines is dependent on individual practice and may not happen at all.
When working with people who may be neglecting themselves in the community the ideal is holistic care, where the reasons for this are thoroughly assessed and the risks are well understood. The provision of this is dependent on everyone involved knowing what is going on and having the opportunity to contribute to discussion about what happens next. This would require good sharing of information and coordination between hospital and community-based services. In addition, it would also require the on-going involvement of primary care in the management of health treatment such as medication prescriptions and its subsequent impact on social care needs. If a patient is frequently presenting to hospital, this information on patterns of admission should be available when they are referred for hospital-based assessments, to enable the risks in the community to be more accurately known.
Finding 4: Increased pressure on primary and community care resources has resulted in home carers being given inappropriate responsibility for service users with more complex health needs when they are untrained to do so and lack the knowledge to react to urgent situations.
This Finding highlights a common systems vulnerability of resource-demand mismatch, for example as there is more demand for primary and community care services currently than they can deliver, for example the role of district nurse would no longer be available to meet the need for adults that require just medication prompting and monitoring in the community. The national legal and policy framework in England has created a system where care can be provided by both Local Authorities, and NHS Bodies, to meet social care and health outcomes respectively. Commissioners have to be pragmatic about the services, which are required to meet the assessed needs in a community. Also, providers should be recruiting and training staff to an appropriate level if they are commissioned to deliver this type of service. Typically, domiciliary care agencies offer training and support to a basic level, with a greater emphasis on social care, meaning that domiciliary social care providers may lack the governance and expertise to provide services to individuals with complex health conditions without clinical oversight and supervision. There did not appear to be any real quality control on either side until something went wrong.
