Case reviews 2018

October, 2018 – Jane

Jane died aged 66. The cause of death was sepsis and gastrointestinal haemorrhage aggravated by gastric ulcers, and a gangrenous left leg due to lymphedema. There had been concerns about self neglect in the years leading to Jane’s death.

Background: Jane lived with her parents until their death and subsequently lived in sheltered housing for four years prior to her death. Jane lived in unsanitary conditions and often declined help from support staff, nurses and family members, wishing to look after herself, which included applying dressing to her legs. Jane is referred to as having a learning disability in some records. Jane told mental health services that she felt better when left alone. Jane was found deceased at home by a sheltered housing officer after neighbours reported having not seen her for 36 hours. The back door was open, with marks around the door frame. Her death was treated as sudden.

Learning Points: After being discharged from the district nurse there was an absence of a ‘Plan B’ for if Jane did not follow through with attendance at the surgery for leg care; Two weeks before her death the Safeguarding Team recommended that multidisciplinary self-neglect pathways should be followed, but this was not implemented; Adult social care were not alerted to the deteriorating condition of her home/personal care; her capacity was taken as a ‘given’ despite escalating service refusal and doubts about her capacity expressed by support workers who knew her well; Risks do not appear to have been proactively managed; Discharged from the community matron’s caseload despite knowledge about the condition of her legs, concerns about the risks associated with her care of them and experience of her non-compliance with surgery-based care; Autonomy was respected above all else; Not clear how much guidance staff have on responding to service refusal; Jane’s story is characterised by agencies working on parallel lines; a At no point was a multiagency meeting held; Agencies could have talked more with Jane’s brother and sister-in-law.

Recommendations: Clarification and dissemination of the open referral policy to staff in all agencies is urgently required; Self-neglect training to take account of national research findings and be delivered on a multiagency basis; Ensure guidance on working with self-neglect includes the possible links between self-neglect and past bereavement; Embed guidance on service refusal in relevant procedures across relevant services; Housing providers to be fully involved in the implementation of multi-agency procedures; Review district nursing and community matron services’ approaches to working with people who self-neglect; Develop templates to support practitioners with assessment of specific risks and development of risk management plans; Review and on-going audit of multi-agency meetings; Confirm that multi-disciplinary team meetings convened by GP surgeries are being used effectively in relation to  adults who self-neglect; Engage with third sector agencies for those who self-neglect and/or are difficult to engage; Multi-agency case file audit to review evidence of how mental capacity is addressed; Offer further training on mental capacity; Multi-agency audit to review standards of recording regarding mental capacity, mental health and risk assessment; Guidance for staff on the routine recording and updating of risk assessments; Hold a learning event to explore the degree to which making safeguarding personal is understood.

Keywords: Self-neglect, Mental health, Self-care, Sepsis, Mental capacity, Consent, Safeguarding, Inter-agency working, Lymphedema, Gastrointestinal haemorrhage

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October 2018 – Nightingale Homes

Three residential homes were closed following multiple failures

Background: During 2015 – 2016 concerning themes emerged about the running of three care homes that were managed by the same organisation. Following a CQC inspections in 2016 all of the homes were rated as overall “Inadequate” and, despite the efforts of a “turnaround” team, the homes closed in 2017. The subsequent SAR revealed poor practice across the organisation and concluded that there was evidence of organisational abuse.

Learning Points: Provider/registered manager struggled with the management of the whole service; there was a lack of insight as to how to improve the service; systems for monitoring the quality of care were not robust; the provider/registered manager had not kept up to date with best practice; staff were unsure how to respond to challenging situations and had no training in addressing individual needs; staff lacked essential skills; staff had no training in or use of specific communication skills; staff had no understanding of using the provisions of the Mental Capacity Act or the significance of the Deprivation of Liberty Safeguards; records and plans were value laden and judgemental; staff congregated together, not engaging with people; medication practices were unsafe; staff implemented inappropriate physical interventions; care was not person centred; the premises were stark and cold; the external grounds were unsafe to walk in; risk management plans were inadequate; care plans were not used, were inadequate and inaccurate; inadequate staffing levels at night and insufficient staff during the day; apprentices were used to deliver care and support unsupervised; people had to follow “house rules”; staff had to contact the owner/manager before contacting emergency services and were unclear what to do in emergency; no on call system; people had to ask to use the toilet and could not enter the kitchen to make snacks or drinks; some staff were reported and observed to be disrespectful, aggressive, shouting and pushing people; people’s money was not well managed by the owner/manager who acted as their appointee; external advice was ignored; health and social care professionals felt they were 'kept at arms-length'; contact with family or friends not encouraged.

Recommendations: SAB should commission the production of a guide on standards to expect from a good care home; SAB to ensure all partner agencies are aware of how and when to contact local adult safeguarding services; clarify what is adult safeguarding, what is poor practice or a “quality” concern; Specify the routes for concerns and the expectations of reporting on all agencies; SAB to share the learning and recommendations with the other SABs; local authorities and CCGs to produce a set of standards for commissioners; local authority to develop a mechanism with which to capture information about individuals placed in its; those with complex needs should be highlighted to the host authority; commissioners must set out their plans for assessing the quality of provision in the local area; develop across agency strategy to promote cultures which welcome and respond to complaints; placing authorities review their systems for planned reviews; ensure families/representatives know how to express concerns: Adult Safeguarding Services should develop a tool to systematically evaluate indicators of potential organisational abuse.

Keywords: Abuse, Organisational abuse, Residential home, Out of area, Person centred care

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July, 2018 – Adult B

A woman in her mid-fifties found to be HIV positive, infected through sexual transmission and unable to consent to sexual relations

Background: Adult B had lived in services provided for people with learning disabilities and autism all her life. Her mother would visit her there. Adult B was clinically classified as having ‘pervasive developmental disorder, unspecified; severe mental retardation; bi-polar affective disorder; and autistic spectrum disorder’. Adult B resisted medical intervention and would become agitated and distressed if she believed invasive testing was to be carried out. This testing was rarely pursued following refusal, and Annual Reviews were also often missed. Adult B was diagnosed as HIV positive following a number of falls and deteriorating health to which medical professionals could assign a cause. A police investigation was initiated as the infection had been sexually transmitted and it was believed that Adult B was unable to consent to having sexual relations.

Learning Points:  Until the months before Adult B’s HIV diagnosis, her tearful distress was seen as behavioural rather than as an undetected health problem; The services to which Adult B is known appear not to have any processes for eliciting stories about her and her family as a means of connecting her life to her present circumstances and the people who are significant; Commissioning did not ensure that the Independent Provider established the necessary conditions to support Adult B; The GPs expected the staff who accompanied her to the practice to be well briefed, in terms of sharing accurate and credible information and competence.

Recommendations:  Court of Protection to give direction in relation to the cause for concern and uncertainty concerning the HIV status of five residents at the care home; Adult B should be provided with additional interim support until she moves to another service (as set out by NICE guidance15); The Transforming Learning Disability Services’ initiative of the CCGs should be embedded in relation to the promotion of greater attention to individual support needs which credibly involves self-advocates and engagement with the families of people with complex support needs; Future changes must ensure that people funded by public services are better/not worse off, reviewing is annual and goals or “ends” are not displaced by undue attention to “means”; Critical skills should be evidenced, such as: collaborating with people with autism and their families; knowledge of effective care planning; knowledge of safeguarding and, specifically, how to record safeguarding concerns; identifying potential community collaborators; and because several medical conditions are significantly more prevalent among people with autism compared with people who do not have autism ensuring that medical appointments are prioritised; The operational competences of specialist providers are known to service commissioners; Provision of evidence that teams are instrumental in working with GPs in detecting health problems, developing health routines such as accessing health screening; Paying particular attention to the challenge of “diagnostic overshadowing”; Promote positive practice in the use of the Mental Capacity legislation; The signs being taught to people with compromised communication skills include the sign for “No!”; Questions must be asked about the mechanisms in place to ensure the safety of people with limited articulacy.

Keywords: Mental Capacity Act, Consent, Personalised care, Family consultation, Autism, HIV, Diagnostic overshadowing, Communication barriers, Annual Review

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June, 2018 – Ms A

Death of a 54-year-old woman found unconscious in the bath

Background: Ms A was a woman with severe learning disabilities, aged 54 at the time of her death. Ms A had exhibited very challenging behaviour from an early age and had several physical health issues. In the 2 years prior to her death she lived in a supported living flat. She had a 24-hour care package funded through a Direct Payment (rather than receiving care from the accommodation provider) of which her sister was responsible. This constant care was provided by 2 workers. Ms A died after being found unconscious in her bath. Pathologists were unable to determine the cause of death or to attribute it to any actions on the part of the carer. Due to what the CPS described as the ‘deliberate failure’ of the carer to call an ambulance, the carer present at the scene was charged with criminal negligence. She was sentenced to a short term of imprisonment; Risks posed by the arrangements were not identified.

Learning Points:  Ms A had suffered from serious failings in both the quality of care and the quality of professional oversight; There was at the time of these events a shortage of appropriate care provision for people with the most complex needs and challenging behaviour; Safeguarding Adults Review Panel members reported that this continues to be the case; the Direct Payment arrangement was made without fully considering whether it was an appropriate response to Ms A’s very specialist needs; No evidence of a care plan, support plan, personal health plan, or risk assessments during the period Ms A was supported by Direct Payments; It does not appear that the different agencies were co-ordinated.

Recommendations: There is a named professional responsible for the effective co-ordination and review of the care arrangements; The CCG should review all current cases in the area where care is funded by NHS Continuing Health Care to ensure that effective care co-ordination is in place. Th ehousing provider should review its guidance and procedures on care reviews to ensure that the review focuses on the lived experience of the service user and supports both service users and families to express their views; The Health and Adult Social Services Management Team should consider how most effectively to disseminate learning from this review through all multi-disciplinary teams; Address the issue of shortage of appropriate care provision for people with the most complex needs and challenging behaviour; Development of joint commissioning strategies; Housing provider should consider enhanced DBS checks as a condition for people employed by Direct Payment service users and whether there is sufficient guidance and support to enable service users with the most complex needs and vulnerabilities to manage their care effectively; The relevant agencies identified should report back to the Board at its next meeting on their considerations and any actions taken.

Keywords: Multi-agency working, Coordination of care, Direct Payment, Family carer

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April, 2018 – Mr B & Mr L

Serious injuries were suffered by 2 males with the same medical conditions living in the same care home

Background:  Mr B and Mr L both had profound learning disabilities, cerebral palsy and osteoporosis. Mr B was 30 and Mr L was 63 years old. They both require assistance with every aspect of personal care. They were taken to A & E on the same day, both being found to have suffered fractures to a femur, remaining in hospital for several months following. It was concluded that injuries were probably caused as a result of single handed manual handling (hoisting being conducted by a single worker) which was not in line with the guidelines in place at the care home.

Learning Points: It appears that the ‘moving and handling’ training at the time was general in its nature and application, there appears to be an assumption made that where service users had specific ‘moving and handling’ needs this would be addressed in the service. There is little evidence in the information available to me that this was happening; There is no evidence in the files available that osteoporosis was identified as an increased risk; The prompt identification of the safeguarding concerns by staff in the Emergency Department, which led to the consultation with the Trust Safeguarding Team and notification, was good practice; However, both forms lacked detailed information and there is no explanation of the ‘safeguarding concerns,’; The police should have been the lead agency and should have been involved at an early stage; There appears to be a communication failure between different teams; Agencies, including hospitals, should not be reliant on or make assumptions about how another agency will respond; The review highlighted the confusion that can arise when a hospital covers more than one area; It is important to ensure that all staff are fully aware of the roles of other teams.

Recommendations: SAB to ensure any indication that a vulnerable adult might have sustained a serious injury should be responded to immediately; there should be a process in place to ensure that the identification of agency staff working is confirmed; Care Plans for residents with osteoporosis should clearly identify the condition and the additional risks it poses; SAB should have in place a pain identification tool; audit adult safeguarding concern forms; Geographical team split should be clear; ensure staff are aware of when to involve the police; all Enquiry Officers and Enquiry Managers have to have specific training for the role; ensure it provides sufficient clarity for staff undertaking complex safeguarding enquires; Section 42 enquiries to be supported by clear action plans; involve the individual and their family in safeguarding enquiries; review minutes of meetings; ensure forms are completed correctly; a culture of openness and willingness to work with other agencies is required; ensure the Orchid View recommendations are being monitored for compliance across the sector, including homes specialising in care for individuals with learning disabilities; the police should ensure that they undertake/lead investigations in cases of complex unexplained injuries sustained by vulnerable adults’; the local authority should review the way it discharges its market management duty under the Care Act to ensure that it understands the quality of care being delivered; safeguarding Lead Members should not hold outside interests with local provider organisations that might appear to raise a conflict of interest with the post they hold; ensure out of area care home placements reviews are undertaken within required time scales; ensure care plans are personal.

Keywords: Manual handling, Serious injury, Profound learning disabilities, A & E, Cerebral palsy, Osteoporosis, Vulnerable adults, Safeguarding

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March, 2018 – P

An adult with learning disabilities who is believed to have committed a number of sexual assaults over a 10-year period.

Background: P was taken into care at the age of 11, following ongoing neglect and sexual abuse. P had mild learning disabilities. As a young person, he demonstrated signs of sexually abusive behaviour and several allegations were made against him. When P turned 18 years old he was placed in a residential home for people with learning disabilities with behaviour that challenges. P remained at the care home for the following decade. During this time several allegations of sexual abuse were made against him. Not all the incidents were reported to the police or local authorities. Following the rape of another resident, a Safeguarding Concern was triggered. Other sexual assault allegations then became apparent in relation to young people in the local community and other residents in the residential home. 

Learning Points: The local authority should have recognised the level of risk; The local authority should have prioritised safety and containment as P became an adult; All incidents should have been properly recorded and allegations should have been taken more seriously and reported to the police and SAB; Psychiatrists acting for the Criminal Prosecution Service and defence solicitors should have been briefed about P’s reported past offending; Psychiatric assessments should have been shared with Adult Social Care and used by the local authority to consider the appropriateness of P’s current placement; None of the residential staff held qualifications in relation to this area of work; Staff could and should have prevented several of the assaults; A proper record should have been curated and shared across agencies; Placing authorities should have a proper system that flags concerns and an annotated history of offending behaviour.

Recommendations: CQC should take note of risks from one service user to another and examine risk management strategies; Staff should have been held to account; People who have been sexually abused by a perpetrator who has learning disabilities should be supported on the same basis as any other victim; At the conclusion of legal proceedings, reports should be formally shared with social care agencies; Enhanced transition planning should take place where necessary; Where a person may need to be constrained for their own protection or that of others consideration should be given to whether they qualifies for detention under the 1983 Mental Health Act; Sexual Risk Orders should be considered, consultation with police used as a tool to inform practice, and MARAC (Multi-agency Risk Assessment Conference) and MAPPA (Multi-agency Public Protection Arrangements) should be considered; Resources should be identified locally that support service providers to assist people with learning disabilities to develop a positive sense of their own sexuality; Residential home providers are responsible for accessing primary health care for service users; GP’s should be reminded that they are responsible for commissioning detailed psycho-sexual evaluations; Transfer key information about service users to the host authority; SABs should review their guidance; Placing authorities should ensure the provider has a suitably skilled staff team; Care Quality Commission should be proactive in making connections with other settings managed by the same provider in order to satisfy themselves that these failings are specific to one setting and not occurring across the whole organisation; NHS England and CCGs should work with Adult Social Care teams to identify areas of specialist health care provision that are currently difficult to commission/provide.

Keywords: Sexual assault, Mild learning disabilities, Neglect, Historical abuse, Police, Criminal Prosecution Service, Record keeping, Offending history, Sexual Risk Orders

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March, 2018 – Christopher

Male died in hospital aged 31 years following a cardiac arrest

Background: Christopher had a unique set of learning and physical disabilities, including, cerebral palsy, epilepsy and learning disabilities, and Autism He also had short bowel syndrome and Crohn’s disease. Christopher lived with his family until 14 months prior his death and had attended boarding schools and respite care throughout this time. He moved into supported living following suggestions from his father that he may be capable of this independence. The social intervention team suggested supported living rather a residential home. There were concerns that Christopher found the transition difficult; he demonstrated challenging behaviour and began to refuse medications, drinks and/or food. Christopher had a history of refusing to eat or drink when he was anxious. This escalated and he lost increasing amounts of weight. Soon after his hospital admission, Christopher was assessed as not having mental capacity to make decisions regarding his medication and his nutritional/hydration intake. An IV and naso-gastric tube are inserted by means of general anaesthetic. Christopher died from cardiac arrest that month.

Learning Points:  The degree and nature of family involvement was never clarified/reviewed; Little or no support was offered to Christopher to explore what the move to supported living meant for him; Family contributed their knowledge, understanding and advice about his history and mental capacity; The response when Christopher began to say that he did not feel listened to was not timely; Family were not invited to a professional meeting the month before Christopher died; The “informal” or on-going nature of mental capacity assessment with respect to nutritional intake resulted in deferred decision making; There was confusion about the care plan for Christopher; A potential role for an advocate was not appreciated earlier.

Recommendations: SAB to review the application of thresholds for enquiries involving concerns about neglect and self-neglect; Review the use of escalation routes when agencies are concerned; Review the content and outcomes of single agency training on safeguarding; Review the content and impact of single agency and multi-agency training on Mental Capacity Act assessments; Undertake a multi-agency case file audit on the standards of mental capacity assessments; Seek reassurance that staff are equipped for meeting the needs of learning disabled adults with complex needs; Seek reassurance from all involved on how family members/advocates are involved at and beyond an individual’s transition; Supervision practice should emphasise frequency and degree to which oversight of a case is challenging as well as supportive; Maximise the strengths and address the challenges regarding commissioning arrangements for placements; Review practice regarding the provision of advocacy for adults with complex physical health needs and learning disability; Reassure required regarding key working to ensure coordination and review of complex; Promote guidance on an adults at risk pathway and on the convening of multi-professional and multi-agency conferences on complex cases, including the availability of specialist learning disability practitioners and legal practitioner; Commission a review of other cases involving transition to supported living, using the learning from this case; Develop practice guidance on best practice regarding transition.

Keywords: Independence, Supported living,Mental Capacity Act, Best interests approach, Gastroenterology, Cardiac arrest, DNACPR, General anaesthetic, Weight loss, Independence, Transition, Neglect, Transition, Learning disability specialists

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March, 2018 – Danny

Death of 64-year-old male following a series of hospital admissions

Background: Danny was understood to have borderline learning disabilities, mental health issues (including Pre-psychotic Episodes) and diabetes. Danny lived most of his life with his family and lived in his own flat for the last 10 years of his life, with twice daily support to maintain his independence. In the 6 months prior to his death, Danny attended A & E on a number of occasions, being admitted as an inpatient for the majority of these. Issues included abdominal pain, diabetes related issues, skin infections, mental health. There were also worries that Danny was being financially exploited. Danny dies as a result of a cardiac arrest in his flat. The coroner concluded: “Left ventricular failure; hypersensitive heart disease and diabetes mellitus”.

Learning Points: There is evidence that the agencies considered Danny’s mental capacity in relation to finance, accommodation and surgery although the hospital did not consult a relative/person close to Danny where best practice would dictate they do; There is evidence of consideration of capacity to buy and consume foods detrimental to his heath condition; His capacity to make decisions about his diet and going out alone required review after hospital discharge; Danny was not able to leave the hospital which in line with his capacity assessments was a deprivation of his liberty; A referral to the Court of Protection should be made to authorise any restrictions; Significant weight does not appear to have been given by the commissioners to the views of the Care Provider, who had known Danny over a long period of time; Insufficient notice and instruction given to the Care Provider that Danny was being discharged after lengthy stays in hospital; The Care Plan did not take into account fully the concerns of both family and Care Provider; There was a lack of co-ordination across agencies; Danny had continuity of care provider and support workers over many years; Exceptional care shown by the support worker in visiting Danny regularly in hospital, unpaid and in his own time; The Provider was abile to respond with 24 hours notice to hospital discharge in re-instating a large increased care package using staff known to Danny; The Learning Disability Liaison Nurse was able support Danny in hospital and advise ward staff; Discharge care planning carried out carefully, although not linked in with other agencies.

Recommendations:  SAB should request a review of the Multi-Agency Hospital Discharge Policy to ensure that it sets out best practice in making safe and effective arrangements for people with complex needs; SAB should be assured that multi-agency care planning, including advocacy, is in place for people with complex and deteriorating co-morbidities, taking account the views of the Care Provider and family; Funding responsibilities need to be clear in order to avoid delays in services in compliance with the Care Act 2014; Local authority, CCG and hospital should explore providing additional support from support workers familiar to the person for people with substantial difficulties when in hospital; All agencies should continue to work towards improving understanding the Mental Capacity Act and Deprivation of Liberty Safeguard; Practitioners need the confidence and support to establish capacity when it is unclear or fluctuating.

Keywords: Mental Capacity Act, Deprivation of Liberties, Borderline learning disability, Diabetes, Multi-agency working, Care Plan, Care coordination, Family, Cardiac arrest, Supported living

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February, 2018 – Joint Serious Case Review 1

The sexual exploitation of children and adults with needs for care and support

Background: A 21-year-old woman with learning disabilities made a statement about sexual exploitation over a long period of time. The extent of sexual abuse in the area was reassessed to reveal multiple victims including people with learning disabilities. It appeared that over a period of years some perpetrators had abused hundreds of victims, some during childhood and early adulthood. The following learning points and recommendations are specifically in relation to the people with learning disabilities who were victims.

Learning Points:  The cases included an adult who was at continuing risk of financial and sexual exploitation. There was no record of any assessment of learning disability during childhood but as part of the safeguarding adult’s processes, she was assessed as having a significant learning disability, sufficient to support an application to the Court of Protection for authority to deprive her of her liberty; There is a difference in the language used in the education, health and social care services.

Recommendations: The Safeguarding Children Board and Safeguarding Adults Board should arrange for guidance to be issued to practitioners on the differences between learning disability and learning difficulties and the relevance for safeguarding judgments and services; No assumptions should be made about cognitive impairment and in safeguarding processes appropriate assessments always need to be considered; There is a need to develop protocols between education and social care services to provide for what action social workers should take if concerned a child may have cognitive impairments or a learning disability; Specialist Learning Disability Liaison Nurses should work within the Safeguarding Adults team, providing support to ward staff and community staff. The records of patients with a learning disability should be flagged so all services are aware and make reasonable adjustments.

Keywords: Sexual exploitation, Reasonable adjustments, Semantics, Learning disability assessments, A common language, Training, Learning Disability Liaison Nurse, Safeguarding, Records

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January 2018 – Drina

Drina was a 35-year-old Romania national with severe learning disabilities. She was found to be a victim of Modern Slavery in the UK and was repatriated to Romania one month later. The processes followed for this were deemed ‘seriously flawed’.

Background:  Drina, a Romanian national, had resided in the UK for approximately two years when she was found ‘dirty, dishevelled and smelling of human excrement’ by bailiffs attending a property. Drina was found to be a victim of Modern Slavery in November 2016 and repatriated to Romania one month later in the care of her stepfather. It was said that it would be in her ‘best interests’ to be within her own community. Drina indicated that she had been abused by her stepfather.

Learning Points: Safeguarding concerns of an extremely poor standard were identified, no risk assessments and non-compliance with legislation and guidance; Poor police investigation; Drina was accompanied back to Romania with her stepfather, whose care and involvement with Drina was not satisfactorily explored by agencies; Necessary safeguards were not put in place on her repatriation, contravening legislation and guidance for addressing Human Trafficking and Modern Slavery; the rationale for repatriation was seriously flawed; Failure to follow: Care Act 2014, Modern Slavery Act 2015, European Convention on Human Rights and other legislation; There was no forward safeguarding planning or consultation with the Romanian Social Services prior to her returning home.

Recommendations: Complex cases of Human Trafficking and Modern Slavery require an appropriate closure of a Multi-Agency Case Conference or Discharge Strategy Meeting with Adult Social Care Legal Services inclusion beforehand; Need to consider both National and Inter-National complexities that can arise; Staff must understand that the voice of a victim with learning disabilities needs to be heard by utilising the services an IMCA and appropriate interpreters, with a Mental Capacity Assessment completed by suitably trained staff; Greater awareness of Human Trafficking and Modern Slavery across services and in the wider community; Potential suspects in a safeguarding case are not allowed to participate in meetings; Ensure policy and procedures of Human Trafficking and Modern Slavery is disseminated to all key practitioners; Agencies must be aware of the requirements in relation to medical examinations; Victim’s allegations shared with relevant agencies; Documents to be promptly uploaded; Review criteria for carrying out SARs in complex Human Trafficking and Modern Slavery cases; Ensure medical examinations are carried out when a resident in a care home or elsewhere shows signs of physical abuse.

Keywords: Modern Slavery, Mental Capacity Act, Modern Slavery Avt, Repatriation, Human Trafficking, Best Interests, Multi-agency working

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January 2018 – Mendip House

Abuse by staff and systematic failures at a residential home for people with autism

Background: Staff abused residents at a home for adults with autism. Poor oversight of staff and a sustained failure to address the abuse of residents occurred over at least a 4 year period. This abuse was psychological, physical and financial and took a variety of forms. Examples included residents paying for support workers lunch when outside the residential home, throwing pens, food and games at residents, violence between service users was not addressed, poor staff resulting in diminished care and support included widespread use of mobile phones, bringing children to work and playing computer games.

Learning Points: Practices occurred which did not identify or act on evidence of bullying; Staff were not managed appropriately; Days were organised around how certain members of the staff team wish to spend their time; Timekeeping is a major issue; There is a general practice of ignoring the mobile phone policy; No policy concerning when it may be acceptable for staff to bring their children onto the premises; Obvious failures in compliance were apparent; The Deputy Home Manager should be far more proactive in their supervision and oversight of the staff team; Involvement of other professionals was sporadic; CCG does not appear to have been kept informed of the wellbeing of individuals; No clear delineation of what constitutes healthcare need as opposed to a social care need; The nature of the commissioning role was unclear; There are concerns about staff recruitment, incident reporting, decision-making, disciplinary procedures and the attitude of the senior management; The organisation neither dealt with nor escalated concerns, failing the residents; Reports were not shared beyond senior management.

Recommendations: Following a decision of joint funding a letter should be sent to the relevant local authority and the provider confirming the local authority’s role as lead commissioner including reference to an expectation of joint reviews at least annually; A system is put in place which monitors the frequency of reviews and reassessments and alerts the CCG if a review has not taken place; Greater clarity over dates from which funding responsibility commences; Care providers are made aware of their role in passing information on to the CCG; Expectations on the part of local Partnership NHS Foundation Trust are set out in writing; The local Continuing Healthcare Operational Policy is updated; Develop quality assurance and care review tools; Any safeguarding concerns are fully considered on receipt of CHC applications.

Keywords: Abuse, Bullying, Culture, Attitudes, Autism, Management, Recruitment standards, Safeguarding, Policy and procedure, Systematic failure, Individual conduct

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January, 2018 – JW

Death of a 55-year-old woman due to a severely obstructed bowel

Background: JW was woman with severe learning disabilities, mobility and communication difficulties. She died in hospital aged 55. In May 2013, she had moved back to the community where her family lived, having lived for many years in a residential home in a different part of the country. When she returned, her sisters would visit regularly. She received 24 hour support in a supported tenancy. She was put on the Liverpool care pathway during her stay in Hospital in August 2013 due to a twisted bowel. She survived this admission and returned home. She was readmitted in November 2015 to another hospital where she later died due to complications related to a severely obstructed bowel. This case illustrates the challenge of caring for someone with both a learning disability and complex physical health needs and demonstrates the tendency of practitioners to minimise risk over time and the subsequent lack of a joined up approach to care.

Learning Points: Lack of coordinated care between agencies; Risk assessments take place in silos; A significant number of practitioners are unaware that people with a learning disability have a higher incidence of bowel complications; Services for people with complex needs and a learning disability are commissioned creatively and effectively, allowing carers the flexibility to support service users in a person centred way; Clinicians do not always uphold the rights of vulnerable people in relation to Best Interests under the Mental Capacity Act or fulfil their own duty of care because they may not consult others; Clinicians prioritise family opinion over that of paid carers because they are ‘next of kin’ which can diminish the value of knowledge carers hold so that decisions may not be based on the best evidence.

Recommendations: A holistic approach to bowel management; Joint Learning Disability Team should be take the lead in coordinating care; A lead should be taken by the JLDT who already have a role in coordinating care; JLDT should review service users once a year – Annual Reviews must be timely: JLDT to lead and coordinate care commissioning; care should be a dynamic and person centred; Other practitioners who know the patient best should be consulted and their views recorded whenever possible.

Keywords: Person centred, Silos, Coordinated care, Twisted bowel, Obstructed bowel, Mental Capacity Act, Multi-agency working, Communication

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January, 2018 – Derrick

Concerns regarding a potential Mate Crime following the death of a 51-year-old male

Background:  Derrick was a 51-year-old man living in supported accommodation. Derrick had lived with family until four years prior to his death, when he lived in independent, supported accommodation. He was close to his family and lived locally to them. There had been concerns that Derrick was a victim of Mate Crime whilst living at the accommodation – his previous flatmate amongst others had taken belongings from him and he had been financially exploited. The days prior to his death this had seemingly escalated. Following his death, there were concerns that this was a contributing factor, however, three Post-mortems and an inquest concluded that Derrick died of a heart attack that could not have been caused by another party.

Learning Points: No consistent understanding/awareness of Mate Crime in the city or that it could manifest as a form of disablist Hate Crime; Training on this issue is lacking; Derrick moved out with little preparation or review meeting; There was a lack of professional follow-up or challenge if there is no feedback or response to a safeguarding referral; Partnerships should be equipping all organisations to challenge each other effectively; Police did not know Derrick had additional vulnerabilities or lived in supported accommodation; Professionals did not suggest the possibility of making contact with various victim support services that would have been available to Derrick.

Recommendations: Re-establish the Disablist Hate/Mate Crime Working Group to lead improvements; Consult with adults experiencing Mate Crime in the local area in order to learn from lived experiences; SAB to update the regional Joint Safeguarding Adults Policy to include Mate Crime; Hold a conference to raise awareness of Mate Crime; Training offered/advertised to support professionals to identify/respond to Mate Crime; Police to develop their system in partnership with care commissioners to ensure that supported accommodation addresses are flagged on their system; Resources developed to support adults to recognise and report Mate Crime; Develop an information sheet for families to be provided when their relative moves into a care or supported accommodation setting; Promote Hate Crime services with care and supported accommodation providers; Local council to provide assurance to the SAB about how they are ensuring the timeliness of reviews undertaken in supported accommodation settings and how reviews of adults moving from respite into long-term provision are prioritised; Organisations commissioning accommodation and care services to expect commissioned services to have a specific Mate Crime policy in place, or have a specific Mate Crime section in their Safeguarding policy as part of the commissioning criteria; Guidance on making safeguarding referrals should be issued by the SAB to ensure that all referrals to the Safeguarding Adults Team are acknowledged in writing and advising that organisations should only consider a safeguarding referral to have been made when they receive such an acknowledgement; SAB to develop best practice guidance on how care and accommodation providers should balance an adult’s right to independence with effective family engagement. 

Keywords: Mate Crime, Borderline learning disability, Independence, Supported living, Heart attack, Family, Hate Crime, Risk, Safeguarding, Police reporting, Victim support services

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2018 Case Review Summaries | V1 April 2020


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