UPDATED: Multi-Agency Risk Management (MARM) documents

We have updated the documents relating to the MARM subgroup, including the MARM referral form and guidance. Please do familiarise yourself with the new documents.

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Safeguarding Adult Review in respect of DJT podcast transcript

Thank you for listening to this short podcast on behalf of the West Sussex Safeguarding Adults Board, about the Safeguarding Adult Review in respect of DJT.

Firstly, I would like to share a little information about DJT, as described by those who worked with and knew him well.

DJT, was a Polish man who worked as a painter and decorator for most of his life. He was the proud father of two sons and a daughter, and enjoyed cycling, football, swimming, music, and cars. He was described as a caring man with a good sense of humour.

Sadly, DJT’s eldest son died at the age of just 21, and subsequently, his marriage ended. Following the death of his son, DJT’s alcohol use increased. He then experienced further trauma from an incident at work, where a sharp object penetrated his eye which resulted in him needing surgery; he then developed glaucoma and lost some of his sight.

These life events caused DJT to become dependent on alcohol, which led to him making unwise choices and self-neglecting in areas including his personal hygiene, nutrition, and financial responsibility.

DJT’s children had minimal contact with him, and as a result, did not contribute to this Review. DJT sadly passed away in hospital in May 2021 of multiple organ failure, related to his alcohol use.

Now, I would like to explain the circumstances which led to the need for DJT’s Review.

Over time, DJT was supported by four different care agencies, but there was some evidence of possible neglect by two of the care agencies, in that they were not providing all the support they were commissioned to deliver. In August 2021, following DJT’s death, a SAR referral was made to the Board due to concerns that there were areas of multi-agency learning, including:

  • Multi-agency risk assessment
  • Assessment of mental capacity
  • Consideration of DJT’s previous history and trauma
  • Person-centred approaches
  • Responses to quality concerns, and
  • How effectively DJT’s physical health needs were met.

Our review looked at actions of the involved agencies and made recommendations to improve practice to reduce future risk. These recommendations were in relation to; person-centred care, including supporting adults with finances and medication; trauma-informed approaches; multi-agency working and coordination; mental capacity (particularly for adults who are self-neglecting); safeguarding referrals and thresholds; and consideration of fire safety measures and fire risk assessment.

The review also identified areas of good practice, including the acknowledgement that Sussex Police went above and beyond their remit to support DJT. After finding him out in public, they escorted him to the shops to purchase food supplies and then took him home, where they spent an hour cleaning and tidying for him. Two representatives from WSCC also went above and beyond their remit, accompanying DJT to several banks to help him sort out his finances, and spent a considerable amount of time trying to resolve his benefit issues. In addition, Rehabilitation Officers from the Visually Impaired team, also known as ROVI, provided significant support to DJT to help his cope with his sight loss, helped him to resolve issues in relation to his finances, and provided emotional support.

So, what can you do to improve practice and reflect on the findings of DJT’s Review?

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

To help you do this, please see our accompanying learning briefing and the full Review on our website. The learning briefing includes questions for you and your colleagues to consider. There are also other useful resources on our website that are relevant to this Review. These are:

  • The Sussex Multi-Agency Procedures for supporting adults who self-neglect
  • The Safeguarding Thresholds document
  • Our Multi-Agency Working and Communication learning briefing and podcast
  • Our Mental Capacity Act learning briefing and podcast, and
  • Our Self-Neglect learning briefing and podcast

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. We appreciate you moving forwards with us to ensure the learning from this Review makes a real difference for those who we are supporting in West Sussex.

Last updated: 29 November 2023