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 John 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 John.

Firstly, I would like to tell you a little about John as described by his niece.

John’s niece held power of attorney for his health and welfare, and provided the Reviewer with information about John as a person, his personality, details of his life, and a view on John’s care and support at the end of his life.

John was an 88-year-old man, who was partially sighted and registered blind. In his earlier life, John served in the military for a number of years, followed by a variety of farm and factory jobs before becoming a postman, a job that he really enjoyed. John married in later life, and became his wife’s main carer, before she sadly passed away from cancer after 15 years of marriage.

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

After fracturing his hip in 2020, John required long-term care at Rotherlea Care Home. He also had some difficulties with his mental health. John sadly died in June 2022 at Rotherlea, after making the decision to end his own life by not eating or drinking.

In the final weeks of John’s life, several safeguarding concerns were raised to West Sussex County Council by the agencies involved in his care. John’s mental health was also assessed, and a number of mental capacity assessments were undertaken by different agencies with differing views on whether John had capacity on the decisions he was making.

It was acknowledged that there were areas where the agencies involved with John could have worked more effectively together prior to his death. The Safeguarding Adults Board therefore commissioned this Review and made a number of recommendations which included areas such as:

  • Being more professionally curious
  • Improving the support we give people who may be at risk of self-neglect
  • Exploring how we can best assess someone's mental capacity, especially if there are differing views between the agencies involved
  • And finally, ensuring the voice of the person and their representatives is central to everything we do

The review did acknowledge, current pressures on agency resources, which will be taken forward by the West Sussex Safeguarding Adults Board.

So, what can we all do to improve practice and reflect on the findings of this Review?

To help others like John, I would encourage you all to check out the West Sussex Safeguarding Adult Board website for a selection of supportive information, tools and resources.

There are learning briefings, covering a range of related topics, such as, guidance on self-neglect and learning briefings on applying professional curiosity. Please also see the information on Mental Capacity Act Assessments for you to share and discuss in your team meetings.

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: 05 December 2023