This short podcast is on behalf of the West Sussex Safeguarding Adults Board and is about a Desktop Review which looked into the involvement by agencies, in the lead up to the death of an adult male in West Sussex. Due to the need for privacy, we will refer him as BK.
Firstly, I would like to tell you a little about BK and the circumstances that lead to him being involved in this Review. BK was a 65-year old man who was found deceased at his home; it was suspected that he had been deceased for around 8 weeks when he was found, although the coroner advised it was not possible to give a precise timescale.
Little is known of his history; he was estranged from his family and had no known local friends. It would appear that he was a solitary man, who had possible difficulties with reading and writing, minor health issues and a minor physical disability that required him to wear a calliper. Before BK’s death, there had been concerns regarding his ability to manage his personal care, a lack of money to buy food and electric and, concerns regarding rent arrears.
Following BK's death, West Sussex County Council commissioned a Serious Incident Review which was completed in July 2020. It noted that, although BK had received involvement from various Health and Social Care teams, there had been long intervals in the time between visits by agencies and missed opportunities for multi-agency involvement.
As a result of the Serious Incident Review outcome the Board progressed with a Desktop Review. The Reviewer was sent information from involved agencies regarding the support offered to BK and was asked to establish any learning about the way in which agencies worked together to safeguard BK and produce recommendations to reduce the risk of similar concerns occurring in the future.
The Review identified six key areas for learning:
The first was, knowledge and implementation of the Mental Capacity Act including; the need to identify and carry out capacity assessments where there are indications of this being required in relation to both housing and care needs.
The second was implementation of the Care Act including; making appropriate referrals for social care assessment or to raise a safeguarding concern, identifying self-neglect and completing assessments, the need to involve advocacy where required, clarifying the remit of safeguarding teams and maintaining contact with individuals who are waiting assessment or discussions at multi-agency forums.
The third was concerns regarding safeguarding practice including; the need for timely onward referrals and escalation of safeguarding concerns, delays in formally triaging safeguarding concerns and clarity of safeguarding concerns being open or closed, which could have led to information becoming separated or duplicated.
The fourth was multi-agency working including; a lack of information sharing, no evidence that screening of safeguarding concerns was multi-agency and that changes in the safeguarding concern referral process were not effectively disseminated within agencies by partner organisations.
The fifth was staff management and supervision including; concerns raised regarding team cultures, the quality management and supervision of staff, oversight, and where required challenge of practice and, management sign off of safeguarding concerns.
And finally, the sixth was Professional Curiosity including, missed opportunities for further investigation and attempts to visit and contact BK, and no record of any attempts to identify and respond to causative factors for his self-neglect.
The Review made recommendations to take forward the learning needed to improve practice and minimise the risk of similar situations reoccurring. The Board have summarised the recommendations under three key areas.
The first is compliance with policy and procedure and process: including; the Mental Capacity Act, making safeguarding personal, the Escalation Protocol, effective supervision and exercising professional curiosity
The second is referrals and assessment: including; appropriate social care referrals, advocacy, onward referrals, particularly with concerns of self-neglect and, maintaining contact with customers.
And, finally the third Information sharing and dissemination: including disseminating information on safeguarding services and informing others of services provided.
The Board are focussed on taking forward and seeking assurance on the learning as a result of this Review. We encourage you to take the time to consider how the circumstances and the learning from the Review can influence and better inform your working practice.
To do this, we ask you to reflect on any areas of learning required, to support your practice to be current and to improve the experience and outcomes of those we support.
Please visit the Board website to view:
The accompanying learning briefing and Executive Summary; and specifically, in relation to this Review: links to the Mental Capacity Act and the Care Act, the pan-Sussex safeguarding policy, the self-neglect policy and briefing and, the professional curiosity learning briefing.
On our website you’ll also find useful links to all our safeguarding policies and procedures, information for professionals, and other Reviews and podcasts.
We thank you for your time to listen to this podcast today and, we appreciate you moving forwards with us to ensure the learning this Review makes a difference for those who we are supporting.