TD Review podcast transcript

This short podcast is on behalf of the West Sussex Safeguarding Adults Board and is about the Safeguarding Adult Review for TD. TD’s Brother contributed to this Review by providing a pen picture of TD and, a perspective on the care received from agencies.

Firstly, I would like to share some information about TD. TD was described by his brother as very caring. They grew up together with their parents and grandparents. TD had a difficult childhood and had a speech difficulty. TD’s schizophrenia began to manifest itself in his early teenage years and subsequently worsened. His brother said that TD could be prone to violent mood swings when not corrected by medication. TD also had complex health needs for which he required a range of services. By his early twenties, TD was working as an apprentice joiner in a factory, before losing this job.

TD had a number of mental health inpatient admissions. During one stay he met his life-long partner. Initially they lived together. However, subsequently they moved into separate accommodation. TD experienced a couple of moves, before becoming a resident at Abbots Lawn from May 2018.  

In November 2019, TD died in St Richards Hospital aged 63-years-old. A Coroner’s Inquest found that TD died from pneumonia, caused by his Chronic Obstructive Pulmonary Disease with the decline accelerated by his mental health. The coroner concluded that interventions by agencies did not amount to neglect or contribute in any significant way to TD’s death.

However, in the eight months prior to his death, there were concerns raised about abuse and neglect including:

• pressure damage to TD’s sacrum, heels and rib area,
• being found on the floor with weeping eyes and
• an alleged assault by staff member.

In preparing for the Inquest into TD’s death, there was found to be concerns, relating to risk management, safeguarding decisions and actions.

The West Sussex Safeguarding Adults Board commissioned a Safeguarding Adults Review which sought to reach an understanding of the facts, analyse these facts and produce findings and recommendations to improve services and, to reduce the risk of repeat circumstances. The Review was completed through a shared commitment to openness and reflective learning and, identified the following general findings relating to all of the involved agencies:

The first there was a lack of multi-agency information sharing, decision-making and risk assessment and management.

The second was around Safeguarding Adults thresholds and enquiries. It was found that there was a lack of action to address risk factors and a lack of line management oversight and recording.

The third finding was about Mental Capacity Act training and recording as Mental Capacity Assessments and Best Interest Decisions were not evident.

The final finding was about the Service User Voice in that the voice of TD, his partner and family did not appear to be actively listened to.

The Review made recommendations under five key areas. These were: planned and completed actions; multi-agency risk management; safeguarding thresholds and enquiries; Mental Capacity Act training and recording and the service user voice. The Board is seeking assurance that multi-agency actions created from these recommendations are implemented to reduce future risk.

For this Review to be meaningful and help others like TD, please use the learning from the Review to reflect on how you can update your practice.

To help you do this, please see our learning briefing which accompanies this podcast and Review. The learning briefing includes questions for you to consider and, which you can discuss with colleagues also.

Please visit our Board’s website to see the accompanying learning briefing and full Review and, also, specifically related to this Review, please see:

• Our MSP Learning Briefing and Podcast
• Our Information sharing guide and protocol
• Our Escalation and Resolution Protocol
• The Care Act
• The Mental Capacity Act
• And, the Pan-Sussex Safeguarding Policy and Procedure

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.