Case Reviews 2017

December 2017 – Mr C

Mr C died aged 66. The cause of death was sepsis, pneumonia, a urinary tract infection, and severe malnutrition. Questions were raised about the transitions between institutions before his death.

Background: Mr C had a diagnosis of mild learning disabilities, epilepsy and a history of psychotic depression. Mr. C had lived independently in supported housing in the same village for many years and was well known to both the community he lived in and the care team that supported him. After a series of moves of placement, Mr. C’s behaviour deteriorated, he stopped eating and drinking resulting in a deterioration in his physical health. On admission to an acute hospital his condition was said to be related to behavioural rather than physical causes. Mr C was discharged to a Nursing Care Home 10 weeks later where he received end of life care and died 4 days later. The coroner concluded that death was due to natural causes contributed by self-neglect. 

Learning Points: Transitions were conducted in an unplanned way; Mental Capacity Assessments identified a lack of capacity to make decisions about appropriate and safe living arrangements – these decisions were made using appropriate Best Interests framework; whilst Mr C’s brother requested that those caring for him knew him best and were best placed to make every day decisions for Mr. C, he was not involved in any of the placement decisions and was not involved/informed of decisions regarding the moves; the cumulative effect that these moves had on Mr. C was not recognised; medication was given covertly via appropriate application of Deprivation of Liberty Safeguards; Care Programme Approach (CPA) was used to good effect; GP received copies the CPA ; a referral to dietetics for support was not undertaken; the staff at the hospital made reasonable adjustments and used advice from his carer; the hospital did not have a Learning Disability Liaison Nurse; various members of the Community learning disability team, his social worker and staff from the assessment unit offered support to the ward; hospital identified that an IMCA was necessary; there were delays in funding the Nursing Care Home; when Mr. C was discharged to the NCH he was placed on end of life care pathway – this was unexpected.

Recommendations: Transition plan should be clear and consider all the needs of the person; consideration of use of Care Programme Approach during acute hospital admissions where it is in place pre-admission and include planning for discharge; identify within the hospital passport how a key worker for a person with learning disabilities will be identified; create an endorsed MCA Toolkit and guidance of when there should be application to the Court of Protection; guidance developed/updated related to the different IMCA and advocacy services; families to be involved in important decisions or be informed of important information (where involvement unwanted/declined); where a care provider is listed as NOK, the rationale for this is recorded and family details are included where relevant; SAB to consider a model for multiagency communication; SAB must ensure learning from this review is disseminated to all agencies.

Keywords: Sepsis, Pneumonia, Malnutrition, Transitions, Mental Capacity Act, DOLs, LPS, Hospital Passport, Inter-agency working, Care plan, Self-neglect, Multi-agency communication

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November 2017 – Mr EF

Mr EF died of natural causes in hospital. Questions were raised about some of the care he received.

Background:  Mr EF was 71 years old when he died. He had complex health and care needs including a severe learning disability, severe challenging behaviour and autism. He was able to make simple everyday decisions but had been assessed as lacking mental capacity for decisions on more significant matters. He had limited ways of communicating verbally. He formed close relationships with the staff looking after him and they were able to communicate with him, understand and meet his needs, and empower him to take decisions over daily matters. Mr EF’s health deteriorated over the last 14 months of his life requiring numerous hospital admissions and spent 50 days in hospital. During the final admittance, following a fall, he became increasingly unwell. A ‘Do Not Attempt Resuscitation’ Order was put into place. A request for an Independent Mental Capacity Advocate was made but not in time for one to attend. Mr EF passed away two days later.

Learning Points: Mr. EF received a good, non-discriminatory service from his GP; Mr. EF’s complex health needs were managed without ‘diagnostic overshadowing’; Mr. EF received personalised care; staff involved carried out their roles professionally and showed interest in, and commitment to, improving Mr. EF’s wellbeing; staff from many organisations and in different roles had tried to work together but were impeded by the inadequacy of systems to support them; the requirements of the Mental Capacity Act are not yet fully embedded in practice; when an individual lacks capacity and has very frail health conditions, care must be taken to avoid attributing unexplained physical injury to health conditions and concerns reported; advocacy should be put in place for people with learning disabilities towards the end of life; vital lines of communication were not instigated between all key agencies; assessment and care planning was not coordinated between organisations; Each person with entitlement to Continuing Healthcare who has learning disabilities and other co-morbidities should have an appropriate professional lead.

Recommendations: SAB should receive assurance from the hospital that actions in relation to consent for treatment and DNAR have been embedded; SAB should receive assurance from all agencies that when an individual who has deteriorating health and who experiences an unexplained fall or a significant number of falls in a short period of time that result in injury; fall incidents reported to the local authority in order that any emerging pattern or concern about the reason for the falls can receive an appropriate response; people with LD who also have deteriorating co-morbidities should have their needs related to approaching end of life included in their assessments and be considered for multi-agency advanced care planning; key agencies should be involved in the assessment and care planning for people with complex health conditions; the agency who knows the person the most should be the professional organisation who takes responsibility to call a multi-agency meeting; explore the possibility of additional support in hospital for people with LD; SAB should facilitate a multi-agency learning workshop.

Keywords: Challenging behaviour, Autism, Complex needs, Assigned professional lead, Care coordination, DNACPR

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July 2017 – Robert

A man was found hanged in his home following the death of his father and being formed of his eviction from his accommodation.

Background: Robert was diagnosed with Foetal Alcohol Syndrome (FAS) and there were references to Robert having a learning disability. He was the registered carer for his father up until his father’s death. Robert was reported to be suffering from low mood and depression and was on anti-depressants. Upon notification of his father’s death he was informed by the company that manages the local authority’s properties that whilst he could not succeed the tenancy of the family home and despite protestations from his sister Robert was served a Notice to Quit the property. Later that same day, Robert was found hanged. He was aged 32 years at the time of his death. There had been no completed assessment of his vulnerability or his care and support needs prior to the eviction decision.

Learning Points: The lack of face to face contact with Robert as part of the housing assessment led to poor quality information being provided to the Decision Panel meetings on both occasions and a case conference could have prevented this; if personal contact had been made with Robert and his sister it may have resulted in a more thoughtful way of delivering the Decision Panel’s determination; the key agencies did not assess or understand the nature and extent of Robert’s vulnerability, nor his care and support needs as any needs assessment was delayed or deficient; the completion of referral forms by Key Support Housing should be more thorough and consistent to avoid ambiguity when making referrals; staff may not be as familiar with the Mental Capacity Act 2005 as they should be; there were some delays in communication between agencies which indicate a lack of management oversight of the referral processes; whilst a number of frontline staff from different organisations were trying to support Robert, there was a lack of co-ordination between them.

Recommendations: A multi-agency protocol is developed between the housing provider, Adult Services and other relevant agencies to enable a better co-ordinated arrangement in assessing and responding to the needs of vulnerable adults threatened with or at risk of homelessness; the housing management company ensure that training and clear guidance are available alongside any change in housing policy so that all relevant staff understand and can explain them to tenants; the housing management company review the workings of their Decision Panel; housing staff have an up to date understanding of adult safeguarding roles and responsibilities, and are supported to identify adults at risk of harm, abuse and/or neglect; improved awareness of the Mental Capacity Act, specifically in relation to the requirements for relatives to act and make decisions on their behalf; within Adult Services, referrals and requests for assessments relating to vulnerable adults are responded to and completed in a reasonable time.

Keywords: Safeguarding, Vulnerability, Bereavement, Mental health, Housing, Mental Capacity Act, Multi-agency communication, Care coordination, Learning disability assessment

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June 2019 – Jo Jo

Death of a 38-year-old female with Down’s syndrome. Cause of death was recorded as: (a) subarachnoid haemorrhage with underlying hypoxic brain injury; (b) right lateral sinus thrombosis; and (c) severe scabies with superimposed bacterial infection.

Background: Jo Jo had Down’s syndrome, needed support with personal care, nutrition, dressing, finances and maintaining personal relationships. Jo-Jo lived with her mother and her stepfather. Her mother was her main carer. It was believed by all services that Jo Jo had severe eczema. Jo Jo would no longer allow her mother to treat this. Her mother sought help from a GP (who had not previously met Jo Jo) who diagnosed her condition instead as Norwegian Scabies and arranged an emergency dermatology appointment for the following day. During the hospital appointment, Jo Jo died following two cardiac arrests.

Learning Points: Assessment using the Mental Capacity Act was never considered; Jo-Jo’s mother was let down by the assumption that she was managing; community nurse visit was not followed up; there were systematic failures to support the family; Outcomes for individuals were seemingly ignored; it is unclear how the assessment form and support plan were created; no functional links between service provision and commissioning; Incorrect diagnosis of Jo-Jo’s skin condition; no pain management; lack of clarity of the role of the care agency; no overall case management; no risk assessment was carried during the 11 months prior to death; no understanding of the lived experience of Jo-Jo; no provision of advocacy; no consideration of safeguarding referral; Failure to consider the Care Act 2014, Mental Capacity Act 2005 or previous learning from reviews.

Recommendations: SAB should seek updated progress on the actions that have resulted from each agencies’ Individual Management Report (IMR); SAB should establish an overarching SAR Action Plan covering individual IMR progress and the recommendations set out here; ensure agencies carry out annual health and social care reviews and check progress and outcomes of these; each key agency should be asked to demonstrate how they are supporting staff to use the Mental Capacity Act; any training and development should be practically based; the key principles of Valuing People Now and the Care Act 2014 should be reinforced focussing on the needs of people with learning disabilities and their carers; Neglect Strategies should consider neglect concerns beyond self-neglect and hoarding; Health Commissioners should work directly with the GP surgery to ensure that the findings of the LeDeR are fully considered; these findings should be shared more widely with health care providers to support good practice; GP surgery should be supported to review its use of practice meetings; the document called FACE Overview Assessment form should be urgently reviewed to ensure that it meets the needs of personalised care for people with learning disabilities and that it meets the requirements of the Care Act 2014; when services are commissioned there should be clarity of purpose and the provision monitored to ensure needs are met; ensure all appropriate professionals are invited to input at multidisciplinary meeting; carer’s needs to be considered in line with the Care Act 2014.

Keywords: Down’s syndrome, Scabies, Care Act 2014, Mental Capacity Act 2005, Risk assessment, Personalisation, FACE

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June 2017 – Lee Irving

A young man with care and support needs who was 24 years old when he was murdered.

Background: Throughout his life, he was involved with a number of services focussing on his complex special needs. His cognitive function was not clearly measured until 2009, when he was assessed as having an IQ of only 56. L was bullied at school and could be easily led. On leaving school at 18 he was described as a very vulnerable young man who was socially immature and impressionable. L developed a pattern of behaviour of accepting bullying and committing crimes to maintain face and ‘fit in’. The cause of death was given as respiratory failure due to severe injuries all of which were consistent with sustained physical beatings. The relationship between L and his killers was described as one of subservience with L beholden to the primary perpetrator for drugs and shelter and where L looked up to the primary perpetrator and desperate to fit in tolerated continued violence and abuse. This coercion and drugging were used to control him and prevent him seeking help.

Learning Points: The cumulative effects of risk factors were not weighed or considered in a multi-agency forum when planning for his care; some agencies, including police and probation services failed to share information or raise appropriate safeguarding referrals when risk was identified; information sharing between agencies is important for instance where there may be worker gender preference issues for the person or their family as these preferences would be considered when a worker is allocated; many agencies dealing with him failed to identify concerns around his capacity and therefore did not adhere to the Mental Capacity Act (2005) which would have required them to undertake a capacity assessment; as a consequence of a lack of co-ordination a number of options for intervening in the case of L were not considered.

Recommendations: The Safeguarding Adults Board examine their guidelines concerning the management of Safeguarding Alerts to ensure that they are individually scrutinised and that the cumulative effect of a number of alerts is seen as an escalation of risk to be separately considered as a priority; the Safeguarding Adults Board examine the transition from Children’s to Adults’ Services to ensure as smooth and integrated a process as possible; examine the realities of partnership working with particular emphasis on joint decision making, the inclusion of all relevant agencies and the consideration of legal options; a Senior Mental Capacity Act “Champion” is appointed in all statutory agencies so as to ensure ownership and a high degree of familiarity and compliance.

Keywords: Multi-agency working vulnerability, Multiple-risks, Transition, Information sharing, Bullying, Mental Capacity Act, Drugs, Alcohol

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April 2017 – Child J

Death of a 7-year-old girl with mild learning disabilities.

Background: Child J was born with mild learning disabilities and a kidney condition. Her mother was a single parent and had poor mental wellbeing; her father had several other children and had spent time in prison. Mother disclosed having thoughts of harming Child J and made allegations of abuse against the paternal grandmother, father and father’s new partner. Child J became a Child in Need. She was placed with a foster family at 4-years-old and received support from child and adolescent mental health services after showing signs of having experienced significant early trauma. She was placed permanently with her aunt (her father’s sister) under a Special Guardianship Order, with support under a Family Assistance Order. During this time the aunt stated Child J was self-harming and deliberately misbehaving. Several concerns were raised about the aunt’s punitive parenting style, including a referral to the NSPCC helpline. Her aunt, who she lived with, and paternal grandmother were both sentenced to imprisonment for child cruelty.

Learning Points: The importance of recognising the impact of parental mental health on children’s wellbeing and giving parents a clear outline of concerns and actions they need to take as part of any rehabilitation process; the importance of helping children understand the reasons for being in care and addressing this through appropriate life story/direct work; working effectively with the impact of early trauma on children’s lives; the importance of a clear understanding of self-harm; addressing the complex health needs of children including working effectively with continence issues; the important role of schools in safeguarding children; the importance of a good assessment of potential non accidental injuries.

Recommendations: The Safeguarding Children’s Board should highlight the importance of recognising and understanding early childhood trauma when communicating the learning from this sub-group; the implications of parental mental ill-health are understood and fully addressed in plans for children and young people; professionals should not accept the term self-harm in children under 10 without consideration of potential emotional well-being or safeguarding concerns; all professionals who are working with children who experience continence issues are aware of the national guidance regarding this; agencies need to be clear about what action to take when parents/carers adopt a significantly punitive approach and recognise the need for a coordinated response to these issues.

Keywords:  Child death, Physical abuse, Punishment, Special guardianship orders, Self-harm, Mental health, Continence issues

Report not publically unavailable

March 2017 – Mr C

A young man died from an epileptic seizure in a placement deemed not suitable for his needs which failed to communicate effectively with his family.

Background: Mr C was a young man with autism, learning disabilities and uncontrolled epilepsy. His family wished to move him from a Supported Living accommodation far away to one closer to home that supported his complex needs. This was arranged and Mr C lived in the care of a charity, under a service commissioned jointly by a Local Authority and the NHS. He died unexpectedly the day after having suffered an epileptic seizure.

Learning Points: The support provided within Mr C’s Supported Living Accommodation was not always well planned and did not occupy or satisfy his needs; his new residence was not a specialist autism unit and his family had reservations that were not dealt with or heard in a proactive way; there was an undercurrent of hostility or irritation on behalf of a few staff towards Mr C’s parents; support plans were in place but not followed, specifically relating to epilepsy; communication was frequent between Mr C’s parents and both the commissioner of care and managers of the supported living, however, it was not always effective in ensuring that each of the parties were aware of all the issues and concerns; there does not appear to have been any regular supervision or monitoring of staff despite a support plan and numerous concerns being raised by Mr C’s parents, about attitudes, behaviour and quality of care and support. 

Recommendations: A truly person-centred approach must be adopted when assessing the needs of individuals with the intention of commissioning a placement, whether supported living or another type of living arrangement; commissioners should listen to the concerns of families, involve them positively in all aspects of support, and take positive and effective action when a problem arises; where relationships with parents are tense, poor or strained there must be a robust process and system for escalating up an organisation, so senior management can oversee and supervise a solution; systems for the applications for Deprivation of Liberty Safeguards should be addressed as a matter of urgency to ensure they are robust and appropriate.

Keywords: Epilepsy, Autism, Placement failure, Communication with relatives, Deprivation of Liberty Safeguards

Report not publically unavailable

March 2017 – X

Suicide of a homeless man who had recently moved to a new local authority.

Background: X was a 59-year-old biological male who also sometimes presented as female. X was known to statutory and voluntary services over many years because of challenging personal and social circumstances. X was diagnosed with Paranoid Personality Disorder and possible learning disabilities. X’s condition was said to be characterized by frequent episodes of self-harm and self-neglect. X could also be threatening and violent towards others and had issues with overeating. X was vulnerable to bullying and intimidation. X moved local authorities shortly before the death to an area with no connections and considered ‘intentionally homeless’ by the local authority. X had difficulty in engaging with the services offered and was particularly resistant to mental health assessments. X was found dead in a caravan deemed to be suicide.

Learning Points: There are currently no arrangements in place for the notification of a person’s move to a different LA where an alert remains outstanding; given the extent of information available to all the agencies concerned it would have been clear even at an early stage that X was a vulnerable person with complex needs and that a planned coordinated multi-agency approach was needed; it is not clear that the housing team took into account X’s specific and very complex needs and vulnerabilities as a trans person when making their decision about eligibility and allocation of housing; given what was known of X’s forensic medical history, his presentation and vulnerabilities as a transgender person and concerning behaviours (self–care and violence), a care coordinated pathway to address X’s personality disorder should have been considered as a viable treatment option.

Recommendations: Where it is known that an individual subject to a VAAR or any equivalent from another authority is resident in the area, the receiving  LA should seek information about the alert from that authority and undertake their own multi-agency risk assessment to determine what action is needed by them; when reaching a decision about access to services the LA should ensure that all efforts are made at the earliest stage to establish a full history to include housing and medical records; Mental Health, Homeless and Learning Disabilities Team should review their service user engagement strategies particularly as they relate to people who are diagnosed with or suspected of having a Personality Disorder to ensure that this accords with best practice; the SAB needs to satisfy itself that all agencies represented on the Board who work with the homeless population understand the wider remit and value of safeguarding policies and procedures.

Keywords:  Vulnerability, Trans, Self-neglect, Self-harm, Personality disorder, Community care assessment, Homelessness

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March 2017 – Child A and Child B

Two children were physically and sexually abused while under the care of their legal guardian. 

Background: Child A and Child B are siblings, both aged under five at the relevant times. They have a range of physical and learning difficulties. Their parents have learning disabilities and have received social care services. There had been extensive involvement with health and social care agencies and the Family Court who placed the children with a couple, Mr K and Ms L, under a Special Guardianship Order (SGO). They lived with them for about a year but were removed when evidence emerged suggesting they both had been seriously sexually and physically abused by Mr K. A number of serious criminal charges were brought against him and he received a custodial sentence.

Learning Points: Finding a permanent home outside the children’s birth family, and placing them separately, should have been given greater thought; the children’s distress was too easily ascribed to negative experiences in their earlier lives and professionals might have been more alert to the possibility of other causes; vulnerabilities of the children, and particularly their disabilities, did not always prompt the level of professional watchfulness that they might have done as children with disabilities are known to be much more likely to be abused than non-disabled children; there was an unevidenced optimism that various arrangements within the children’s family would meet the children’s long term needs, which were special and demanding.

Recommendations: The Safeguarding Children Board should use its arrangements for disseminating the learning arising from Serious Case Reviews to highlight the particular vulnerability to abuse of children with disabilities and special needs; The Safeguarding Children Board should require the local authority to demonstrate that it has used the findings of this review to inform its arrangements for care planning for “looked after” children.

Keywords: Parents with learning disabilities, Children with learning disabilities, Abuse, Safeguarding, Social care services

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March 2017 – Damien

Death of a man in hospital through self-strangulation

Background: Damien had diagnoses of Asperger’s Syndrome and ADHD. He had a mild learning disability and misused a variety of substances, causing him to come into frequent contact with the police and mental health services. His vulnerability was exploited by others who stole from him and misused his home for their own purposes. In the last fifteen months of his life he was detained under Section 2 of the Mental Health Act on three occasions. He was also made subject to MAPPA arrangements. Damien died in hospital following an incident of self-strangulation in the residential unit that had been his home for two weeks following discharge.

Learning Points:  Meeting the dual requirements of protecting both the public and Damien from harm, at the same time as recognising capacity and allowing him to live his own life with only the necessary oversight and control, tested services.

Recommendations: Ensure the aim of care and support of people in transition is person-centred; Support people in transition in the least restrictive setting available, in line with the Mental Health Act Code of Practice and Mental Capacity Act 2005; involve health and local authorities to work together in the interests of an individual; record the needs and wishes of the person at each stage of transition planning and review; Identify the person’s support networks; enable the person to maintain links with their home community; Mental Health practitioners supporting transition should respond quickly to requests for assessment of mental health from: people with mental health problems, family members/carers, primary care practitioners, specialist community teams (e.g. LD Teams); staff such as housing/community support workers should take account of the expertise and knowledge of the person’s family/carers, and involve them in risk assessment planning; allow more time and expert input to support people with complex, multiple or specific support needs; ensure there is a designated person responsible for writing the care plan in collaboration with the person being discharged, and their carers if the person agrees; discuss the person’s housing arrangements to ensure they are suitable for them; mental health practitioners should carry out a thorough assessment of the person’s personal, social, safety and practical needs to support discharge, including risk of suicide; identify a named practitioner who will ensure that the person’s family members, parents or carers receive support and timely information; respect the rights and needs of carers; discuss follow-up support with the person before discharge.

Keywords: Person centred care, Metal health, Mental capacity, Planning, ADHD, Asperger’s Syndrome, Mild learning disabilities, Transition, Self-strangulation, Suicide, Family involvement

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January, 2017 – X

The coroner concluded the probable cause of death of X was Methadone and Diazepam toxicity.

Background:  X was understood to have learning disabilities to some degree, although this had not been assessed. There were complex relationships, interdependencies and possible domestic abuse/coercive control between X and his two brothers. X had numerous convictions for offences including criminal damage, theft, drugs and firearms. X had attempted suicide the year prior to his death, jumping out of a window and sustaining an injury to his brain. Shortly before his death, X was interviewed by the police on a voluntary basis in relation to an allegation of historic sexual abuse. This interview was suspended when it became apparent X needed an Appropriate Adult. X was found dead before the interview was able to take place. The coroner concluded the probable cause of death was Methadone and Diazepam toxicity.

Learning Points: X’s mental capacity was not formally assessed; the support of an Appropriate Adult could not be secured in a timely manner; chaotic lifestyles and inconsistent compliance can result in people being described ‘hard to reach’ which may not be relevant to the urgency of people’s deteriorating circumstances – this is possibly the case here; X was in contact with a wide range of services, however, there were issues with arrangements for managing this work.

Recommendations: Workers need to be able to identify the requirement for a metal capacity assessment and make appropriate referrals; a partnership agreement is required for a pathway to secure support for an Appropriate Adult Board agenda item to raise awareness of suicide prevention.

Keywords: Undiagnosed learning disabilities, Suicide, Brain injury, Police, Appropriate Adult, Domestic Abuse, Methadone, Diazapan, Multi-agency case, Mental capacity, Interagency working, ‘Hard to reach’

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2017 Case Review Summaries | V1 April 2020

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