Jill

Date of SAR	December 2021
SAR Reviewer	Making Connections – Eliot Smith
Owner	Monuara Ullah – LB Hounslow

EXECUTIVE SUMMARY

Contents

Introduction
The circumstances that led to a safeguarding adult review being undertaken in this case
Views of the adult at risk
Terms Of Reference
Process of the Safeguarding Adults Review
Facts of the case
Analysis of the case

1. INTRODUCTION

“Local Safeguarding Adults Boards must arrange a Safeguarding Adults Review when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is a concern that partner agencies could have worked more effectively to protect the adult” (Department of Health, 2020).

Background

This Safeguarding Adults Review concerns the death of Jill, a 93-year-old woman who died in hospital from septicaemia on 24 September 2018. Jill had been admitted to hospital with multiple infected pressure sores over her sacrum, spine, shoulder, chin, and neck, which were deeply necrotic and malodourous. Jill had a diagnosis of dementia and severe frailty; she had difficulties with mobility, and continence, and was fully dependent in all activities of daily living.

During her last years she was cared for by her son. Jill had a daughter who lived in Ireland and who kept in regular contact with her mother and brother. Jill has been described as fiercely independent and had been intent on remaining at home.

Principles

Safeguarding Adults Reviews should support a culture of continuous learning and should be systems focused – incidents can provide the opportunity to learn about how people who have care needs are supported and protected from harm.

Safeguarding Adults Reviews must adhere to the six safeguarding principles outlined in Care and Support Guidance (Department of Health, 2020); these are Empowerment, Prevention, Proportionality, Protection, Partnership and Accountability. The purpose of a Safeguarding Adults Review is not to hold any individual or organisation to account, but to give practitioners the opportunity to be “involved in the review and invited to contribute their perspectives without fear of being blamed for actions they took in good faith” (Department of Health, 2020).

Statutory Guidance states that Safeguarding Adults Reviews “should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again” (Department of Health, 2020).

Reviewing expertise and independence

This Safeguarding Adults Review has been led by an Eliot Smith, an Independent Health and Social Care Consultant on Behalf of Making Connections (IOW) Ltd. Eliot Smith is an experienced Independent Reviewer trained in root cause analysis and the SCIE Learning Together methodology. Eliot Smith has had no previous involvement with this case and is independent of the London Borough of Hounslow.

Methodology

The review methodology will draw on systems learning theory to evaluate and analyse the information and evidence gathered about the case of Jill. In addition to documentary evidence and organisational chronologies, the review will consider data and any evidence provided by practitioners. As significant that has passed since Jill’s death much of the evidence and data for this review may come from historical records and any interviews carried out with practitioners as part of investigations carried out at the time. Members of Jill’s family will also be offered the opportunity to contribute to the review’s evidence base.

In the drafting of findings, the approach adopted in this review will be to explore the range of organisational factors that may provide a context to Jill’s death. The Review seeks to bring out findings from this case that have general applicability for the wider system; they are presented thematically against the structure provided by the Terms of Reference set for the review.

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

On 14 September 2018 the Ambulance Service were called Jill’s son after she had been unresponsive for two days. Agencies have recorded that Jill was found lying in her own urine and faeces’ and had high grade pressure sores. The house was described as ‘filthy, dirty and had an unpleasant odour’. Jill was immediately admitted to hospital and died on the 24 September 2018.

As a result of her physical condition on admission, her frailty and dependence on others, and agency concerns about the care she received leading up to her admission to hospital, her case was made subject to safeguarding enquiry under section 42 and a police investigation which concluded without any charges being brought. The London Borough of Hounslow referred Jill’s case to the Safeguarding Adults Board to explore possible failings by social care agencies and health to protect Jill from harm amounting to neglect.

3. VIEWS OF THE ADULT AT RISK

Jill has been described as ‘a character’. She was someone who could be “stubborn independent, proud, private, opinionated”, someone who “would not be told what to do”. Members of Jill’s family have provided some background on their mother for the Coroner’s Court. Their summary indicates that Jill had some very strong and fixed views about how to keep herself and her home. Jill is described as a person who would not willingly accept the support – or interference – of others in the way she lived her life. In her latter years, Jill was diagnosed with dementia. By the time she was admitted she was very unwell, and it was not possible to assess her ability to make decisions about her care or treatment. The evidence submitted to the Coroner’s Court and to this review has been extremely useful in providing a social context to Jill’s experience of living at home with her son prior to her admission to hospital on 14 September 2018.

4. TERMS OF REFERENCE

The Terms of Reference for this Review will be drafted in consultation with the London Borough of Hounslow Safeguarding Adults Board, guided by the following areas that the Safeguarding Adults Board would like the Review to consider:

Referral and assessment: How do Adult Social Care respond to urgent referrals and requests for assessment? Following an urgent referral, why was not assessment carried out on this adult and why was there no direct contact with either the adult or their carer?
Safeguarding: Did the safeguarding system respond appropriately to concerns about Jill’s welfare? Did Social Services fail to act on a safeguarding concern raised in 2015 by the London Ambulance Service?
Living conditions and maintaining a suitable environment: How did health services respond to concerns about Jill’s living environment? Did relevant NHS services fail to act on this resident’s living conditions? Did the GP respond appropriately?

5. PROCESS OF THE SAFEGUARDING ADULTS REVIEW

This Safeguarding Adults Review has been undertaken using systems learning theory and in accordance with the London Borough of Hounslow Safeguarding Adults Review Policy. The scope of the review, and Terms of Reference were agreed by the Safeguarding Adults Boards of the London Borough of Hounslow.

Agency involvement

The following agencies were invited to contribute to the review:

Adult Social Care
Primary Care (General Practice)
Community Health NHS Trust
Acute Hospital NHS Trust
Ambulance service

The Safeguarding Adults Review considered documentary evidence submitted by involved organisations and the input of practitioners involved in his care.

Practitioner events

An important part of any Safeguarding Adults Review is the meaningful involvement of practitioners and organisations who were involved in the case. The purpose of a Safeguarding Adults Review is not to hold any individual or organisation to account, but to give practitioners the opportunity to be “involved in the review and invited to contribute their perspectives without fear of being blamed for actions they took in good faith” (Department of Health, 2020)

There are significant challenges involved in carrying out a retrospective review over three years since the death of the adult and enabling the meaningful contribution of practitioners. A richness of analysis may be obtained through examining with practitioners the changes in the system over time and keeping a focus on what could be learnt from the past about the current system. This Safeguarding Adults Review is taking place at a time when public health measures to contain the Covid-19 pandemic have had a significant impact on the traditional direct engagement event model of practitioner involvement.

Practitioners and professionals involved in the care and treatment of Jill were offered an interview to discuss their recollections of the case and offer views and opinions on care and to share their expertise and perspectives on safeguarding systems in the London Borough of Hounslow. Professionals working in the system can have a unique perspective on the local, organisational, and systemic factors that influence culture and practice. Crucially, this can include the context in which decisions are made which may have a positive or negative impact on the wellbeing of people with care and support needs.

6. FACTS OF THE CASE

Jill’s physical condition at the time of her admission to hospital and death was extremely serious. The post-mortem report records that Jill was malnourished and suffering from generalised oedema, psoriasis to her lower legs, and mild scoliosis. Jill was immobile and had experienced cachexia – weakness and wasting of the body due to chronic illness. The report also records bruises to her left ankle and leg, and multiple pressure ulcers at various stages, including multiple infected ulcers on her back, one reaching the bones.

A feature of this case is the relationship between Jill and formal health and social care. Jill suffered from underlying health conditions including ischaemic heart disease and dementia, however had little ongoing support or monitoring from primary or secondary healthcare services, having been discharged from the Cognitive Impairment and Dementia Service (CIDs) in 2015.

Chronological information identifies three potentially significant episodes of care or contact with health and social care agencies – each offering an opportunity to gain information about Jill’s social circumstances and care. These include a referral to Adult Social Care in 2013 for day care input to ‘reduce social isolation and provide Jill’s son respite’, a safeguarding alert raised in 2015 amid concerns about an unexplained fall, and possible neglect of Jill and her environment, and health input in 2015 and 2018.

Contact between Jill and her family and health and social care agencies was not always straightforward. For example, retrospective views of the relationship between Jill and her GP practice differ for example about the willingness of Jill and her family to accept – or GP practice to provide, a home visit. What is clear is that at this time Jill was unable to engage directly with health services, and that all contact was brokered through Jill’s son and daughter. This limited contact between Jill and health or social care agencies, and the limited contact between Jill and her family at all, outside of these contacts, provides some context and an indication of the reluctance of Jill and her family to engage with health or social care agencies.

7. ANALYSIS OF THE CASE

This section considers the learning from the Jill’s case within the context of the terms of reference set by the Safeguarding Adults Boards. The findings generated through analysis of documentary evidence and involvement of practitioners in the case are focused on systems learning, rather than on Jill’s part, her family, or any individual or agency involved in her care and support. Findings are intended to identify practice issues that can be generalised from Jill’s case to the wider system.

General findings

The legal frameworks that govern the provision of health services and adult social care are built on values of personal autonomy and self-determination. Legal frameworks in England and Wales seek to protect key concepts of autonomy including the right to bodily integrity, the right to respect for privacy and family life, and the assumption of mental capacity. Citizens are empowered to make decisions about their care and treatment, and safeguards are in place to curtail the interference of the state in a citizen’s private and family life. Where public bodies do engage an individual’s human rights this must be done proportionately and out of necessity.

TOR 1: Referral and assessment

How do Adult Social Care respond to urgent referrals and requests for assessment? Following an urgent referral, why was not assessment carried out on this adult and why was there no direct contact with either the adult or their carer?

In October 2013 an urgent referral was made to the Local Authority for day care, to ‘reduce social isolation’ and to give Jill’s son some respite from his caring role. At the time of referral this request would have been considered under pre-Care Act 2014 legislation, that is under the National Health Services and Community Care Act 1990 (NHS & CCA 1990), and the Carers (Recognition and Services Act) 1995.

It was decided on the facts of the referral, but without direct assessment or direct contact with Jill that she did not meet criteria for a service. This was a missed opportunity to work with Jill, and a failure to undertake a social care assessment, something that under section 47 (NHS & CCA 1990) could have taken place. Jill was not seen, and her Community Psychiatric Nurse was signposted to non-Local Authority, self-access services and community support. Section 1 of the Carers Act 1995 allowed a carer to request that the local authority carry out a carers assessment, before they make their decision about the needs of the relevant person – the focus being on enabling the family member to continue to provide care and to meet the needs of the relevant person.

In culture and practice, as well as though policy and legislation, individuals were seen has having a right to assessment and support from the state, but were also required, in most cases, to seek it, or to ask for the support they need. It is often only in the context of safeguarding, risk, public protection, or mental illness, that such an assertive approach is taken.

Across the health and social care system there remains a strong emphasis on working closely with service users and their families, minimising the role of the state as the controlling agent in the provision of their care and support. The emphasis on family involvement, representation, and advocacy is important, but should not be at the expense of a practitioner’s ability to remain professionally curious. The majority of abuse and neglect of adults with care and support needs occurs at the point of care delivery, in the place where they live.

As in child safeguarding practice, professional curiosity is not about undermining a person’s family relationships, but about achieving a balance between reliance on family members and direct assessment, contact, and triangulation of experience with the person themselves.

At the heart of Jill’s case, was a failure by the multi-agency system to recognise when Jill was no longer able to act autonomously and to make her own decisions about her care, support, and treatment needs – and to be clear under what legal frameworks decisions could be made on her behalf. As her mental health deteriorated and her dementia progressed, Jill become unable to make decisions or arrangements for her own care. She became increasingly dependent on her son to not only provide her care, but to make decisions about how her care should be provided.

The Mental Capacity Act 2005 provides a legal framework for decision-making, protecting individual’s rights to autonomy and self-determination and ensuring that people are supported to make decisions while they are able. The Mental Capacity Act also, through best interests1 also makes provision for decision-making on behalf of individuals who are not able to make their own decisions. In relation to specific decisions, respecting the assumption of capacity and protecting those who do not have it requires a careful balance. The Code of Practice to the Mental Capacity Act 2005 sets out when a person’s mental capacity should be assessed (Department of Health, 2007). Of relevance in the case of Jill, paragraph 4.35 includes the situation when “the person’s behaviour or circumstances cause doubt as to whether they have capacity to make a decision” (Department of Health, 2007).

While it is important to begin with an assumption of mental capacity, direct contact, and an assessment of Jill’s community care needs and ability to make decisions about her arrangements would have provided the opportunity for her mental capacity to be assessed in relation to her living environment and care. A failure to assess her mental capacity in relation to care ultimately left her more disempowered and with less autonomy and self-determination.

1 S.1 (5), and S.4 MCA (2005)