Safeguarding Adults Reviews

GG

Date of SAR February 2019
SAR Reviewer Pinnacle Social Work Services Ltd & Passiton Consultancy Ltd
Owner LB Hounslow - Monuara Ullah

EXECUTIVE SUMMARY

List of Contents

  1. Introduction
  2. The circumstances that led to a safeguarding adult review being undertaken in this case
  3. Views of the adult at risk
  4. Terms Of Reference
  5. Process of the Safeguarding Adults Review
  6. Facts of the case
  7. Analysis of the case

1. INTRODUCTION

This Safeguarding Adults Review (SAR) has been commissioned by Hounslow Safeguarding Adults Board (SAB) in line with its accountabilities under Section 44 of the Care Act 2014. The authors have been selected to ensure independence of the review and in terms of their background experience, inclusive of; enhanced and substantial experience of operational and strategic multi-agency safeguarding practice, with relevance to this case in terms of the application of the Mental Capacity Act 2005 and working with self-neglect.

The core timescale for the review spans the period from July 2013 to October 2017 but also has regard to any relevant previous history in this case. In order to protect the individuals and family’s confidentiality, the individual subject to the review will be known as GG for the purpose of this overview report.

This review process is an individual case and appreciative systemic enquiry into the actions and decisions taken by the relevant agencies in relation to GG, and a review of those decisions within the context of the real working conditions which existed at the time.

Research has shown that methodologies that engage practitioners in reviews are more likely to achieve learning and promote change in practice. Therefore, the participation of frontline staff is extremely valuable, and such engagement aims to improve the quality of the overall review and the commitment to taking the lessons learned back into practice.

A SAR is not an enquiry into how someone died or suffered injury, or to find out who is responsible or to apportion blame. Its purpose is to:

  • Look at any lessons we can learn from the case about the way all professionals and agencies worked together;

  • Review the effectiveness of safeguarding adults’ practice, policy and procedures;

  • Inform and improve local safeguarding practice for all agencies involved; and

  • Deliver an overview report with findings for consideration by the SAB.

The key outcome of a SAR is to improve the safeguarding of adults in future. For this to happen as widely and thoroughly as possible, professionals need to be able to understand fully what happened and what needs to change to prevent the likelihood of reoccurrence.

It is the aim of Hounslow SAB to further promote a learning culture by nature of this review and to effect maximum positive change in both single agency and multi-agency working arrangements to ensure the best outcomes for adults at risk and the wider community. It is equally important to highlight areas of good practice and to share that learning.

2. THE CIRCUMSTANCES THAT LED TO A SAFEGUARDING ADULT REVIEW BEING UNDERTAKEN IN THIS CASE

GG was an 85-year-old Asian2 male with complex health issues, including diagnosis of chronic schizophrenia3, dementia and diabetic foot and leg wounds4. GG had a son who was actively involved in decisions relating to his care and treatment and visited his father regularly. When residing at his home within the community of Borough X, GG had self- neglected and was often non-compliant5 with professionals regarding his diabetes care and also with care of his ulcerated foot and legs. GG had been placed by Borough X local authority in a residential care home where they became unable to manage his care due to GG’s non-compliance. The placement ended, as they were unable to manage his increasing needs, particularly relating to managing his personal care and the treatment of his health conditions. GG admitted to hospital as result of urgent health6 needs but then discharged back to the residential placement even though they felt unable to manage his needs. GG was again admitted to hospital7, from where he was discharged to a Hounslow Nursing home, where he became subject to a Deprivation of Liberty Safeguards8 (DoLS) authorisation9.

Concerns were raised relating to the quality of the safeguarding investigation10, in relation to the decisions and application of the Mental Capacity Act 200511, and in respect of a reported12 lack of engagement by the placing local authority when concerns were raised. GG sadly died in hospital from a heart attack13 following a lengthy admission, leading to the commission of the SAR.

3. VIEWS OF THE ADULT AT RISK

The review was unable to ascertain the views of GG as he is deceased. His son14 was invited to engage and contribute to the review however declined. It is however evident from recordings within the case, and from conversations with professionals that knew him, that GG was a man who took pride in his appearance and was well presented, GG had a strong personality and asserted his belief that he was able to care for himself.

4. TERMS OF REFERENCE

The Hounslow SARs group set the following questions as terms of reference for the review:

  1. Werethedecisionsmadeornotmadeinrespectoftheadult’scareandsupport needs, in line with expected practice standards and professional accountabilities?

  2. How were legal frameworks applied and duty of care discharged, whilst balancing and promoting the adult’s choice and expressed wishes?

  3. What were the challenges and implications for agencies in working with individuals who either lack capacity or are making unwise decisions?

  4. How do we15 support providers, and facilitate a multiagency approach to managing risk?

  5. How were placement16 decisions informed by assessment of the individuals health, care and support needs and how was this reviewed in line with changing or emerging needs?

  6. Were safeguarding frameworks applied, monitored and reviewed in line with PAN17 London protocols and local policy and procedures?

The terms of reference are used as individual headings to ensure focus and relevance to the analysis section of the report.

5. PROCESS OF THE SAFEGUARDING ADULTS REVIEW

Key agencies involved in the case and therefore requested to participate within the review were:

  • Nursing Home

  • Adult Social Care and Safeguarding London Borough of Hounslow (Host Authority)

  • West Middlesex Hospital (Chelsea & Westminster NHS Trust)

  • General Practitioner (GP)18

  • London Borough of X (Placing Authority)

The methodology selected by the SAB for this review, in line with their local SAR policy was a combination of “significant events analysis” with a “learning together approach”. The reviewers held a series of individual conversations with frontline workers and managers involved in the case and developed a multi-agency learning event based around a timeline of key events in GG’s journey through the health and social care system. Practitioners and managers were invited to provide the reviewers with any additional contextual information, to identify contributory factors, systems prevalence and to work through the key events in order to agree, challenge or clarify the emerging findings.

The key events were identified by submission of individual agency chronologies. These were combined. Agencies submitted supporting documentation relevant to the key events to enable independent analysis and identification of potential missed

opportunities by the reviewers. Where good practice is identified this is reflected in the analysis section of the report.

Where issues have been identified relating to individual practice concerns or areas of risk within pathways or systems requiring immediate review or action, these have been directed to the SAB for their response.

The reviewers note that attendance at the learning event was very limited due to only four attendees representing only two statutory agencies; no health or provider representatives attended therefore limiting the scope of the event.

6. FACTS OF THE CASE

Covered in section 7 Analysis of the Case

7. ANALYSIS OF THE CASE

Were the decisions made or not made in respect of the adults care and support needs, in line with the expected practice standards and professional accountabilities?

A range of practice standards would inevitably be applicable in relation to GG, due to the complexity of his situation and the surrounding legal frameworks.

Communicate effectively

There is evidence of multiple agencies being involved throughout the period within scope of this review and there is evidence of them communicating with each other. However, the content and method of these communications did not achieve collaboration34 around decision-making and discharge35 of accountabilities. For example, whilst information was shared, agencies operated within silo’s around discharging Duties, e.g. the provider was notifying the hosting authority of significant information, they were notifying the placing authority, who were requesting input from Health, but none of this was joined up and key information was not shared with the right people at the right time.

Knowledge and skills

There is evidence of those involved having relevant knowledge of for example, the Care Act 2014 and Mental Capacity Act 2005; however, there are multiple examples of the application of this in practice being below the expected standard (see next section for further detail). This impacts on evidence of defensible decision-making35.

There is limited evidence of holistic assessment and intervention that recognises the complexity of relevant factors and how these interfaces with each other. This means that key elements were not consolidated in order to inform professional judgement and decision-making.

Professional Judgement

There is evidence of professionals being willing to make judgements and respond to the information they held at that time. However, there is limited evidence of the application of professional curiosity to enable more holistic triangulation of information36. The review found that information recorded across the system (in case notes and other documents) when put together, would likely have changed the decisions that individuals reached.

Safe and effective practice

The review does not highlight any concerns about unsafe practice, however when considering the points made above, there is evidence that practice could have been more effective37.

Maintaining records

Records reviewed, demonstrate variable quality and inconsistent compliance38. There are some examples of clearly recorded information, including demonstrating how it has been used to reach decisions. However, there are other instances where information appears to be missing, or is not clear or for example, where capacity assessments are referenced, but with no written evidence. This was acknowledged in both conversations and within the learning event.

It was significant during the review, that when pulled together, relevant information did exist within the system, which should have been available to all and informed more timely and effective responses. This information, however, was not always accessed or utilised in the way the review would expect.

A range of policies and procedures would be expected to apply to the management of GG; ASC Care Management policies and procedures, Adult Safeguarding policies and procedures, Working with Self Neglect Guidance, Out of Borough Placement policy, Deprivation of Liberty Safeguards policies and procedures, Information Sharing protocols and Complex Case protocols (including for dual diagnosis).

There is evidence of some of these being applied, but not all. Where they were applied, they were not always followed appropriately. This created confusion and in effect contributed to a cyclical pattern whereby professionals became distracted by periods of GG complying with care and failed to deal with the underlying chronic nature of the concerns.

Therefore, whilst there is evidence of professionals working hard to try and address the presenting issues, there is vulnerability around overall discharge of professional accountabilities.

How were legal frameworks applied and duty of care discharged, whilst balancing and promoting the adult’s choice and expressed wishes?

Care Act 201

During the conversation with Borough X, it was stated the reason for GG’s initial admission to residential care from the community, and any context about index safeguarding concerns and assessed needs was unclear39.

There is evidence of appropriate and regular statutory review whilst in that placement with reviews undertaken in 2013, 2014 and 2015 – all of which broadly confirmed GG was compliant with care and settled in the placement, with no change in needs – against a documented history of self-neglect.

The first concern raised in relation to changing need was in May 2016 whereby GG was now non-compliant with clinical care and declining all personal care. He had two open wounds on his foot and was malodorous. This information was significant in that it suggested changing needs and whilst a GP and District Nurse were asked to visit, this reasonably should have triggered a review under the Care Act 2014, which did not occur. When this situation becomes prolonged, the Provider raised further concerns with the commissioner and this resulted in a referral to the Care Home Intervention Team to support the provider, but still did not trigger a statutory review under the Care Act 2014. There was also no recorded outcome from the referral to the Care Home Intervention Team so the effectiveness of this remains unknown. It is recorded that GG now has fluctuating capacity, although formal capacity assessment is not evidenced.

Due to further deterioration in circumstances, hospital admission is considered. There are further contradictions about GG’s capacity in relation to relevant decisions. A safeguarding alert is opened but then closed on the grounds GG is assessed as lacking capacity but is compliant with care and treatment and the case is closed to Borough X’s practitioner taking him outside of not only the safeguarding framework, but also outside of the review framework.

The next contact with Borough X is in November 2016 when GG is reported by the residential home to have been admitted to hospital and already discharged back to them, despite them having stated they were unable to meet his needs. During this admission to hospital, GG should have been referred to and allocated by, the Hospital Social Work Team and this would have facilitated reassessment of needs based on what the provider was saying. The fact this did not occur due to a lack of a Section 2 notification being issued was a missed opportunity. At this time, the provider was requesting a review (reassessment) of GG as they continued to maintain they could no longer meet his needs. The GP was referring to GG now being at End of Life and requiring nursing care. During a conversation with Borough X, it was acknowledged there was a delay in responding to this request and information and the reasons for this are unclear, which may be indicative of issues around recording. Instead of triggering a reassessment, Borough X request a CHC assessment40 and the provider was left to manage the situation until it became acute requiring hospital admission via ambulance.

During this hospital admission, a reassessment is undertaken – this assessment is detailed and comprehensive and informs a move to nursing care. However, there is no evidence of a six-week review despite the statutory requirements, the complexity of the case and the cyclical nature of his non-compliance.

In March 2017 the Provider contacts Hounslow requesting assistance with Best Interests Decisions making (following receiving a DoLS authorisation with conditions attached). Hounslow correctly refer the matter back to Borough X highlighting the need for an early placement review – however, the outcome is that Borough X ask the GP to do a Mental Capacity Assessment (MCA) and feedback to them. There is no visit, no review or reassessment. The case should at this point have been reallocated to a practitioner in Borough X, but this did not happen; the impact being that the underlying request and issue remains unresolved with no further evidence of action until a safeguarding concern is raised a month later. This still does not result in a review or reassessment and there is further delay and drift in achieving a coherent response.

Mental Capacity Act 2005

There is evidence of some good process and clarity around decision-makers for different types of capacity decisions, i.e. health and medical needs versus social care decisions. There was some vulnerability evident in terms of how this was applied in practice, where one decision had significant impact on the other and not recognising this, enabled professionals to externalise responsibility for areas of concern. What would have worked more effectively was joint assessment of capacity.

The review identified multiple opportunities and examples of incorrect application of the MCA41. The safeguarding response in May 2016, demonstrated good practice in terms of historical information from the safeguarding enquiry in 2011 (identifying GG lacked capacity regarding personal hygiene) being considered. However, there was a lack of evidence of a formal assessment in May 2016, despite the outcome being referred to that GG had capacity in relation to this decision.

Subsequently, on 1st June 2016 a consultant geriatrician stated the GP had completed an MCA and GG was assessed as lacking capacity regarding personal care, hygiene and wound treatment. It would be required, when a person is assessed as lacking capacity, to undertake a Best Interests decision. Seemingly, because at that time GG was compliant this was not unrertaken42.

Given the known history and cycle of refusal in the case of GG this was a missed opportunity to embed Best Interests within his care and treatment plans. This would have ensured professionals were clear on how to respond during periods of non- compliance and potentially fluctuating capacity.

Further lack of clarity around application of the MCA is evidenced in terms of the hospital admission in November 2016. It is suggested that GG refused treatment and refused amputation but it is not known whether there was a formal capacity assessment or consideration of referral to the Court of Protection43

Despite contradictory decisions about whether GG had or did not have capacity in relation to specific decisions44, interventions present as having a heavy reliance on assumption of capacity and unwise decision-making, even at points of very high presenting risk, which should have triggered further, more detailed exploration of this. It is of note to the reviewers, that significant information was held by the Provider that GG in fact did not accept that the wound was on his foot and therefore he was unable to use and weigh this information in reaching a capacitated, fully informed decision45.

Deprivation of Liberty Safeguards 2007

There was a DoLS application first submitted for GG when he was still residing in residential care on 30/11/16. Due to hospital admission quickly following this, this authorisation does not appear to have been processed.

GG was made subject to two different DoLS authorisations; one during the hospital admission of December 2016 and one in respect of his placement in nursing care in 2017.

All DoLS applications made clear statements about GG’s understanding and insight into his care and treatment needs, including in relation to his wounds and personal care, which was indicative of a lack of mental capacity in relation to these decisions. This information was not utilised or considered in relation to subsequent work or concerns

At the time of the safeguarding concerns in March 2017, practitioners overlooked46 the information that GG was subject to a DoLS authorisation. This is significant in that this authorisation contained conditions, requiring the Managing Authority to engage with the MDT to make Best Interests decisions around delivery of GG’s care and support. There is evidence of the Managing Authority attempting to achieve this, but other agencies failing to understand the nature of what is being requested or the reason for it. There does not appear to be a mechanism in Borough X to monitor conditions on an authorisation, if the customer is not allocated to a practitioner and this led to omission in this case.

The outcome of the DoLS assessment, which clearly evidences capacity in relation to the issues being considered in the safeguarding concern, is not considered or referenced. This is despite it providing robust evidence that GG lacks capacity in relation to care and treatment needs (having failed all four elements of the functional test – understand, retain, use & weigh, communicate) and despite practitioners now contradicting the outcome of this assessment47.

What were the challenges and implications for agencies in working with individuals who either lack capacity or are making unwise decisions?

It is evident throughout the review that despite the presenting facts and some references in case recording to that effect; self-neglect never becomes the focus of assessment and intervention for GG. In particular, there is a lack of application of theoretical understanding in practice, with professionals being distracted by periods of compliance despite the chronic nature of the issues. As a result, issues are evident, of confusion between compliance and mental capacity as a result of which, risk management plans are incomplete and Best Interests decision-making is never embedded in GG’s care and support.

As discussed elsewhere, there is confusion around GG’s mental capacity in respect of relevant decisions; this is compounded by a lack of timeliness in response to an identified need for review or reassessment, particularly in relation to the appropriateness of the placement and the support required by the Provider to meet GGs needs. This creates a cyclical pattern whereby assessment does not inform intervention, which deals with both the chronic and acute nature of the issues.

It was striking in the review, that despite multiple references in recording to GG having a diagnosis of long-standing48 Schizophrenia, this was not reflected in key assessments or care and support planning. This may have been a key factor in the nature and degree of his self-neglect but was never explored. From discussions and the learning event, it is evident that key individuals working with GG were surprised to learn of this diagnosis49. The focus of all those involved at the time was on GG having dementia50 – key people involved have during this review articulated that had they understood the dual diagnosis, their assessment and decision-making may have been different.

There is evidence of use of both care management and safeguarding frameworks with GG. However, the functions of these frameworks are not well delineated. Safeguarding is used as a process, rather than an intervention in that it is used as a tool to try and engage the accountability of the placing authority, rather than to fully assess and understand the nature of the self-neglect, and mental capacity in relation to relevant decisions. This is compounded by using a safeguarding category of ‘neglect and acts of omission’ rather than self-neglect, which detracts from the core issue. Despite conflicting decisions about mental capacity, the framework is not used to address this, and conflicting views are not addressed.

How do we support providers, and facilitate a multiagency approach to managing risk?

Good practice was identified in the review by nature of the Provider involving the son of GG from the outset, in addition to making appropriate referrals to other agencies and professionals for example, Podiatry and Tissue Viability Nurse (TVN).

There is evidence in this review of the provider being proactive in terms of sharing information and seeking input from the multidisciplinary team. There is evidence of them attempting to follow up the DoLS conditions around holding a Best Interests meeting – although they do not appear to explicitly convey this as resulting from a DoLS authorisation, which may impact on the engagement of other agencies. A sense of frustration for the Provider is evident best captured by the following quotes: “We tried to do what we could do. We tried to get other people to help us. I read from the hospital that they tried to do an amputation, but it was a no, no......it was very frustrating. At the end of the day, we should be working as a team. We agreed to meet the person Borough X referred but they needed to support us”. During the review the provider added that the reason they approached Hounslow for support was due to their sense of a lack of response from Borough X, and this resulted in a safeguarding concern being raised by the host authority.

There is the lack of a cohesive multidisciplinary response, wherein an MDT is never convened, which means not all relevant information reaches relevant decision-makers and contradictions in information are not identified. This was particularly notable in relation to the sharing of all relevant information with the placing authority and to the sharing of information about the fact GG did not accept the wound was on his foot (which would have likely changed the outcome of the Mental Capacity Assessments).

In summary, the lack of a cohesive response via an MDT, left a provider doing the best they could to support GG in circumstances of chronic self-neglect and increasing need, with high levels of acute risk.

How were the placement decisions informed by assessment of the individuals health, care and support needs and how was this reviewed in line with changing or emerging needs?

Although it was evident within the review that assessments were completed and contained the relevant information, this was not adequately triangulated or utilised to enable holistic risk assessment and support planning. As such, there were missed opportunities to link information contained in DoLS assessments, which would have informed capacity assessments51 and context and in turn, would have further supported risk assessment and management.

With various agencies involved, it was striking that information was fragmented and although all key information existing in the system as a whole, it was never effectively consolidated to fully inform interventions.

Were safeguarding frameworks applied, monitored, and reviewed in line with Pan London protocols and local policy and procedures?

There were two safeguarding concerns opened in relation to GG during the timeframe covered by this review.

The first was in May 2016. There is good evidence that at the time of this safeguarding concern, practitioners considered history and context in line with best practice and referenced the findings of a safeguarding intervention in 2011, which identified GG did not have capacity in relation to decisions concerning his personal care.

At this time in 2016, there is evidence of some liaison between Adult Social Care and the GP, but agencies act in silo’s and the impact of mental capacity around one set of decisions (personal care) on another set of decisions (wound care and treatment) is not well coordinated. There is no evidence of multiagency planning meetings, professionals’ meetings or case conferences under the safeguarding framework, any of which would likely have improved the quality and effectiveness of information sharing and unpicked any conflicting views.

In June 2016, the conclusion is reached that GG in fact lacks mental capacity in relation to relevant decisions. However, as he is now complying with care and treatment, no Best Interests decision is formulated and this is a missed opportunity52 as having formulated a decision and embedded it in GG’s support plans would have effected a safeguarding plan and ensured effective delivery of care at times of either absent or fluctuating capacity, or non-compliance.

The safeguarding enquiry is subsequently closed in July 2016 due to intermittent compliance. There is no risk management plan in place at the time, and the intervention has not dealt with the underlying issues of self-neglect. This is a missed opportunity as there is clear evidence from the review that the issues are cyclical and were highly likely to reoccur at the time the safeguarding intervention was closed.

The second safeguarding concern was raised in March 2017 by the host authority, following the provider raising concerns about a grade 3-4 wound on GG’s right foot and his refusal of care. The provider was requesting support with a Best Interests decision.

There is evidence of good practice in that it was recognised that there was high risk to GG and that this needed to be managed under a framework. Interestingly, the category of abuse used was ‘neglect and acts of omission’, which is suggestive that the focus was perhaps slightly on the difficulties and delays in getting the placing authority to engage in the issues (as identified during discussions) – rather than using the category of ‘self-neglect’, which would have ensured focus was retained on the core, underlying issues and their cyclical nature.

A decision was made to progress to Sec 42 enquiry and the case was transferred through to the locality team. There is no evidence of multiagency planning meetings, professionals meetings or case conferences under the safeguarding framework, which in line with findings from research on ‘working with self-neglect’ would likely have supported most effective working with GG.

There is some confusion evident from recording about professionals being clear exactly what the safeguarding concern related to; the concerns had been raised in relation to the diabetic foot ulcer and refusal of personal/wound care. However, elements of the enquiry and case recording are heavily focused on the skin integrity of GG’s legs, which although relevant, is not the core issue. This would likely have been clarified via use of MDT forums.

Whilst it is positive that safeguarding concerns were raised, work under the framework, particularly in the context of the latter concern, presents as process focused rather than actually achieving an intervention. A request is made to the placing authority for an early placement review and a request is made of the GP for a mental capacity assessment in relation to wound treatment. The significance of the refusal of personal care to the wider issues is not articulated and assessment around mental capacity is not coherent or well evidenced. Whilst there is discussion and exchange of information – there is no action taken to mitigate risk or to engage GG in line with the principles of Making Safeguarding Personal.

The safeguarding concern is closed in May without a safeguarding plan in place beyond an intent to review the placement – this does not appear to appreciate the cyclical nature and impact of GG’s fluctuating compliance, the complexity of his care and support needs or relevance of the long history of self-neglect. The placement review does in fact not take place for another month after the safeguarding concern is closed and it is clear there was a missed opportunity under the safeguarding framework to bring relevant parties together into a cohesive MDT in order to put a robust safeguarding plan around the situation.

A range of relevant references and guidance are included within section 11 of this report in order to support the analysis and for easy access by practitioners.

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