Our Quality and Performance subgroup have recently carried out an assurance survey for our Safeguarding Adults Review in respect of DJT (PDF, 430KB). Safeguarding Adults Review assurance surveys are a method to seek assurance of learning from Reviews, and are undertaken six months after the multi-agency action plan from a Review is completed. Assurance surveys check that learning has been embedded into practice, and that changes have been made to reduce the risk of similar circumstances occurring in the future.
As a reminder of DJT, he was a Polish man, proud father of two sons and a daughter, and described by those who worked with him as a caring man with a good sense of humour. Following traumatic events of his eldest son dying at 21 years old, his marriage ending, and an eye injury at work followed by development of glaucoma and some sight loss, DJT became dependent on alcohol. This led to him making choices understood to be ‘unwise’ and self-neglecting in areas including his personal hygiene, nutrition, and managing his finances. DJT sadly passed away in hospital in May 2021 of multiple organ failure, related to his alcohol use.
Following a West Sussex County Council Serious Incident Review, our Safeguarding Adults Review looked at actions of the involved agencies and identified five key areas requiring improvement, including:
- Person-centred care
- Trauma-informed approaches
- Multi-agency working and coordination
- Mental capacity
- Consideration of fire safety measures/risk assessment
Our assurance survey asked questions in these five areas, to seek feedback from the five agencies who participated in the DJT Review that learning has been embedded into practice.
On the whole, improvements were noted in all five areas, with some agencies sharing that work still needs to be done but providing assurance that there are plans in place to achieve this.
Within the area of multi-agency working and communication, the most prominent finding was that agencies were not clear on who the nominated staff member should be to lead on multi-agency working. Our multi-agency working resources highlight that any agency can convene a multi-agency meeting, but it is often preferable to be led by the agency most involved in supporting the adult. Please explore the resources linked below for more information and do make use of the templates for multi-agency working in our Multiple Needs Toolkit.
Below are links to some helpful resources to support your work in the key areas for this review.
