Jean Willis Safeguarding Adults Review podcast transcript

This short podcast is on behalf of the West Sussex Safeguarding Adults Board and is in relation to a Safeguarding Adult Review for Jean Willis. Jean’s family have met with the Reviewer and have contributed to this Review. To make sure that Jean’s voice is heard, and with the agreement of her family, Jeans’ name has been used in full in this Review.

Family members strongly believe that there is meaningful learning from the support offered to their Mother, including; quality, co-ordination and planning of care, family support, communication, and assistance in navigating through health and social care systems. The family hope that agencies will use this learning to improve practice.

Firstly, I would like to share some information about Jean. She was an 82-year-old woman and was a much-loved Mother and Grandmother. In the last few months of her life, she needed 24-hour support in a care home which, was on a self-funded basis.

Jean was admitted to hospital on 10th August 2019, after becoming unwell and, sadly, died on 12th August 2019. Her cause of death was Pyelonephritis. This is a type of urinary tract infection where one or both kidneys become infected and leads to sepsis and multiple organ failure. Other significant conditions contributing to Jean’s passing were Alzheimer’s Dementia and Severely Frailty.

A Safeguarding Enquiry was carried out due to concerns about neglect. This concluded that Jean “may have not received an adequate amount of health led input in the prior days to her being admitted to hospital. The care home may have needed to be more insistent with the health services due to not being able to manage her increasing care needs.”

The West Sussex Safeguarding Adults Board commissioned a Safeguarding Adults Review which examined the actions of involved agencies to identify learning. Four key practice areas were considered: decision making leading to Jean’s admission to a care home, co-ordination and oversight of care, person centred care and, timely co-ordination and response to deterioration of Jean’s health needs.

The Review identified 4 key findings:

• Missed opportunity for the co-ordination of care and assessment under statutory and formal frameworks.
• Lack of multi-agency approaches to Jean’s care, with no opportunity for professionals and family to ascertain together, the care required.
• Limited evidence that Jean’s wishes and feelings had been considered.
• A lack of co-ordinated response to Jean’s deteriorating health, such as a Multi-Disciplinary process to ensure a coherent, collective, and timely response.

The Review made seven recommendations. The Board has summarised these seven recommendations under four areas; assessment and review, decision making, person centered care and, interface and support. We encourage you to take the time to consider how the circumstances and the learning from this Review can influence and better inform your working practice.  

We refer staff to the learning briefing which accompanies this podcast and Review. The learning briefing includes questions for consideration in order for practice to reflect the learning required and, to ensure practice is current. This is necessary to improve the experience and outcomes of those we support. The Board is also, seeking assurance that actions have been implemented.

Please visit the Board website to view the accompanying learning briefing and full Review; and specifically, in relation to this Review:

• The Making Safeguarding Personal Learning Briefing
• The Escalation Policy
• Links to the Care Act and Mental Capacity Act
• Pan-Sussex Safeguarding Procedure and,
• National Framework for NHS Continuing Healthcare

On our website you’ll also find useful links to all our safeguarding policies and procedures, information for professionals, and other Reviews and podcasts.

Thank you for your time to listen to this podcast and, we appreciate you moving forwards with us to ensure the learning from this Review makes a difference for those who we are supporting in West Sussex.