Safeguarding Adults Reviews

DD

Date of SAR 7 September 2021
SAR Reviewer Making Connections - Eliot Smith
Owner LB Hounslow - Monuara Ullah

EXECUTIVE SUMMARY

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

Background

This Safeguarding Adults Review concerns the death of DD, a 62-year-old man with Down’s Syndrome and associated learning disabilities. DD was a resident in a residential care home. During the week commencing 14 August 2017, DD was one of four residents admitted to West Middlesex Hospital. Each resident presenting with the same condition, namely aspiration pneumonia. DD was also diagnosed with a grade 3 pressure ulcer on admission. DD’ condition deteriorated on admission to hospital. He was risk fed (fed when appropriate) and struggled to take fluids. DD remained at risk of swallowing problems caused by Dysphagia1. On 18th August 2017, the residential home was deemed to be an unsafe environment. All the remaining residents were dispersed to other care homes. DD died in a Nursing Home on 06 October 2017.

Principles

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. In addition to these, this Safeguarding Adults Review will be conducted in line with the following principles:

  • Culture of continuous learning – incidents can provide the opportunity to learn

  • Proportionality

  • Independence and independent challenge

  • Meaningful involvement of practitioners without fear of blame for actions taken in good faith

  • Involvement of family members and individuals affected by the case

  • Awareness of risks of hindsight bias and outcome bias

  • Focus on system and teams functioning

  • Not a re-investigation of incidents or performance

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 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 DD. 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 DD’ 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 DD’ 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 have come together in unexpected ways, and which provide the context to DD’ 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

“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). The quality of care that DD received whilst in a residential care home was thought to be a contributory factor for his admission at hospital. There are concerns that staff did not follow his dysphagia and meal care plans and it is notable that three other residents were admitted at the same time with similar conditions indicating that concerns about abuse and neglect may have been systemic within the home.

3. VIEWS OF THE ADULT AT RISK

During the period of concern about his placement, DD was no able to articulate his views or wishes. DD had a diagnosis of severe learning disability and down syndrome. DD had limited verbal communication and was dependent on staff for his daily health and social care needs. DD had a half-sister; they knew each other for only a short period of time. DD’ family were offered the opportunity to participate in the review, an opportunity they did not wish to take up.

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:

1. Care Planning:
Was there an appropriate care plan in place to meet DD’ assessed needs, and if so, was it followed? In relation to:

  1. Professional and specialist guidance, including Speech and Language Therapy and Physiotherapy

  2. Skin integrity and management of pressure  areas

2. Provider expertise:
Did the care home staff have the appropriate skills to deliver the care plan, and was support from appropriately qualified colleagues sought to ensure delivery of DD’ care plan?

3. Support planning and review:
Were social care reviews completed DD?

  1. Did they address appropriate needs?

  2. Did they include the multi-disciplinary team?

  3. Was an advocate needed / involved?

4. Supervision and oversight:
In the time leading up to DD’ admission to Hospital in August 2017, did the agencies involved in DD’ care maintain an appropriate level of supervision and management oversight?

5. Regulation and Quality Assurance in commissioning:

Were the CQC or Joint Commissioning Team aware of any concerns about the provider?

  • If so, what action was taken to address those concerns?
  • Following theadult’s admission, the unit was closed at short notice by the care home. Were the actions initiated (and agreed by the Director of Joint Commissioning) proportionate?

6. Systemic provider failure:

Given that three other people (the unit offered care to 7 people) were treated for a similar condition was there any evidence to suggest systemic issues within the organisation prior to the adult’s admission?

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:

  • London Borough of Hounslow

  • Thames Valley Police

  • Hounslow and Richmond Community Healthcare NHS Trust

  • Placement Provider

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

Possible links between DD’ death and alleged neglect and poor-quality care within the placement setting were considered through a full and comprehensive police investigation.

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).

This Safeguarding Adults Review is a retrospective, taking place over three years since DD’ death. The review was fortunate to benefit from involvement of practitioners who knew the case well and who, with the support of documentary evidence, were able to recollect some of the key issues of the time, and who were able to use their expertise to contribute professional opinion to the safeguarding adults review.

6. FACTS OF THE CASE

In August 2017 DD was one of four residents admitted to hospital suffering from aspiration pneumonia. DD had a diagnosis of severe learning disability and down syndrome. DD suffered from eczema and had reduced mobility, relying on a wheelchair and the support of others to move around. DD did not have any verbal communication and towards the end of his life was increasingly drowsy and non- communicative generally. It was recorded that DD was able to express pleasure/displeasure through facial expressions and gestures but that he lacked mental capacity in many areas of decision-making including health and care arrangements, financial affairs, and choices of accommodation). Over the last year of his life concerns about his care within the residential home dated back to 2016, with concerns about a number of quality issues, including but not limited to:

  • Lack of training and associated knowledge deficit in relation to dysphagia and manual handling

  • Adherence to care plans – including specialist care plans formulated by Speech and Language Therapy and Physiotherapy

  • Lack of personalisation of dietary requirements

  • Poor documentation

  • Environmental issues and facilities

  • Overall cleanliness

  • Levels of activity and occupation

  • Poor communication between staff

  • Lack of visible leadership

  • Skin care, repositioning, and pressure area management

On 15 August 2017, night staff at the residential care home reported the morning staff in handover that DD “appeared unwell, and that they had concerns over his breathing”. No action had been taken, and no contact had been made with emergency services or 111.

On 16 August 2017 DD was admitted to hospital with aspiration pneumonia and a grade 3 pressure ulcer to his sacrum. This was his second admission over an eight- week period. Concerns for DD’ health included the aspiration pneumonia, urine infection, acute kidney injury, and pressure ulcer. A risk of further choking was identified as DD was described as “too drowsy” for foods.

Concerns about DD’s residential care home were raised to CQC in the context of three other residents subsequently admitted to hospital, also with similar respiratory conditions. On 19 September 2017 DD was discharged from hospital to a nursing home. He passed away peacefully on 6 October 2017.

7. ANALYSIS OF THE CASE

This section considers the learning from the DD’ 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 individual or agency blame. Findings are intended to identify practice issues that can be generalised from DD’ case to the wider system.

TOR 1: Care Planning

Was there an appropriate care plan in place to meet DD’ assessed needs, and if so, was it followed?

DD lived in a residential care home and was subject to high levels of supervision, care, and support. In addition to general care plans for health and welfare, activities of daily living, social care needs and risks, DD also had specialist care plans that had been developed by registered professionals visiting to support the care home with DD’ additional needs.

Professional and specialist guidance, including Speech and Language Therapy, Physiotherapy, and skin integrity and management of pressure areas

The Specialist care plans produced to support the care home with DD’ additional needs included Speech and Language Therapy, Physiotherapy, and Tissue Viability. These care plans addressed additional need and risks associated with DD’ particular health conditions and needs. Specialist care plans are personalised to the individual service user and should be followed closely. Specific guidance is issued based upon evidence-based practice and are written carefully to avoid confusion or ambiguity. Care plans should be implemented and reviewed under the supervision of the responsible professional.

Speech and Language Therapists had formulated a specific care plan for DD due to his difficulties in swallowing (dysphagia). Dysphagia may describe a number of different swallowing disorders that may occur while a person is eating or drinking, and symptoms can include:

  • coughing during or immediately after drinking and/or eating

  • choking

  • wet vocalisations after drinking

  • change of skin colour

  • watering eyes

  • refusal of food before or during meal

  • increased anxiety at drink/ mealtimes

  • behavioural difficulties at drink/mealtimes

  • Losing food or fluid from the front of the mouth

The early identification and effective treatment of dysphagia is vital. Effective management of swallowing difficulties can reduce hospital admissions and risks of choking, aspiration2, respiratory arrest, and sudden death. Chronic symptoms of dysphagia can include recurrent chest infections, malnutrition, and dehydration. The management of dysphagia can include exercises to strengthen the muscles used to swallow, management of posture while eating, managed diet and thickened fluids, good oral hygiene, and avoidance of sedative medication. As each individual’s swallowing difficulties may be different, people who suffer from dysphagia will need a personalised and detailed care plan with strict instructions on type of diet and level of thickening of fluids. Speech and Language Therapists have a high degree of specialist expertise and will formulate specific guidelines for service users, families, or carers to follow. Failing to follow the care plan accurately can result in a high risk of adverse outcomes or death.

Care plans for DD were in place and reviewed regularly. DD’ dysphagia care plan included strict instructions for food preparation (a pureed diet), fluid thickening (stage 2 fluids) and fortification (a high calorific diet due to risk of low weight and malnutrition). DD was able to be risk-fed, depending on his level of drowsiness, which meant that if managed appropriately he would be able to sustain life through oral intake of calories. In August 2017 concerns had been raised about the adherence to care plans. Speech and Language Therapists had identified that DD was being given soup without appropriate thickening agents, which put him at risk of aspiration and associated respiratory injury. Following DD’ death agencies had investigated the latter stages of his life and the care he received.

The findings from investigations after his death indicated that care plans were in place and reviewed but were not being followed. There was a lack of personalisation and despite residents each having different dietary requirements, and preferences, they were all given the same meals. For DD this meant that he was not receiving a pureed diet or thickened fluids and was being fed foods that were hard to eat or listed in his care plan as foods to avoid. In the management of DD’ diet there appeared to be an interpretation of the care plan for the convenience of the service over the needs, preferences, and risks for service users. It was believed, by practitioners involved in the review, that there was a lack of understanding and knowledge deficit in relation to the importance of the dysphagia care plan, and the risks involved of an unsafe diet. Concerns extended to the adherence to care plans from physiotherapy which addressed equally important issues. There was little evidence of individuals within the residential care home receiving the level of personalisation of therapy, or adherence to exercises designed to maintain health and wellbeing, posture and address risks of atrophy and conditioning. The lack of awareness and understanding of resident’s needs in relation to dysphagia and physiotherapy meant that care plans were not prioritised or followed. Members of staff failed to grasp the gravity of risk, and this placed residents, including DD, at significant risk.

1 The term dysphagia is used to describe swallowing disorders characterised by difficulty in oral preparation for the swallow or in moving the bolus from the mouth to the stomach. Subsumed in this definition are problems in positioning food in the mouth and in the oral movements, including suckling, sucking and mastication

2 Aspiration in this context refers to the inhalation of foreign objects, including regurgitated contents of stomach

rating button