Thank you for listening to this short podcast on behalf of the West Sussex Safeguarding Adults Board about our Safeguarding Adult Review for Beverley.
Beverley’s Review, published on the 2nd March 2023, marks exactly a year since her passing. The request to publish on this date, made by Beverley’s family, aims to provide a legacy to Beverley and to her much-loved family and friends, and shares how lessons can be learned, and services improved for those who use them, and for their families.
We thank Beverley’s family and friends for their significant and highly valued contribution. Her family shared a few words which are included at the beginning of the Review, so I would like to begin this podcast by sharing these with you: “We are extremely grateful for this review being done but also find it very sad that it took our Mother’s, Grandmother’s, Great Grandmother’s, Sister’s, Auntie’s and friend’s death for her voice to be heard.
We hope lessons have been learnt and that the necessary changes will be implemented and that all involved will go away from this and really reflect and strive to remember that within their individual roles, the most important person of a multi-disciplinary team, is the person themselves. Their voice and their family’s voice should always be at the forefront of their care.
Nothing will bring Bev back and she should never have had to go through what she did, but we feel that her voice is being heard now, and lessons have been learnt so that hopefully no one else has to go through what she did. This will be the legacy that Bev left.”
So, now I would like to tell you a little about Beverley as described by her family and friends. Beverley was a 67-year-old lady and a much-loved Mother, Grandmother, Great Grandmother, Sister, Aunty, and friend. She was described by her daughter as a very proud and independent person, and the “matriarch” of a very large family. Beverley had lots of friends and on special occasions, her bungalow was described as “looking like a florist”, which was testament to how well she was thought of. Beverley had a special relationship with all her grandchildren and great grandchildren; being one of seven children herself she loved her large and extended family. Beverley was a lady with many interests including crosswords and reading, she also, enjoyed music and was a big fan of Tom Jones, Rod Stewart, and Gary Barlow.
Now I have shared a little about Beverley, I would like to explain the circumstances which led to the need for her Review.
In 2020 Beverley had a period of hospitalisation and when she was discharged, she moved into a Care Home as she could no longer live independently in her bungalow. Beverley had several health-related issues which had compromised her mobility, including lymphoedema and a wound on her leg. The last few months of her life were incredibly difficult for Beverley. Her leg wound was causing her a great deal of pain, worry and distress. This period of time also corresponded with COVID-19 restrictions increasing the difficultly for Beverley, as family could only visit her through the window or speak to her by telephone.
Beverley was admitted to Worthing hospital and sadly passed away on the 2nd March 2022. After Beverley’s death, a safeguarding enquiry found that improvements could have been made to the support and coordination of care for Beverley, and that she was not always part of the decision-making about her care. After the Safeguarding Enquiry a Safeguarding Adults Review referral was made.
Following this referral our Safeguarding Adults Board commissioned a Safeguarding Adults Review for Beverley. This Review looked to reach an understanding of the facts, analyse these, and produce findings and recommendations to improve services and to reduce the risk of similar circumstances occurring again.
The Review was completed with a shared commitment to openness and reflective learning. Beverley’s Review identified three key findings:
- The first is multi-agency working. The Review found that there was inconsistent application of the multi-disciplinary care plan, and a “separation” of the care home and the wider multi-disciplinary team.
- The second is workforce skills and knowledge. The Review found that care plan and delivery was not always reflective of specialist recommendations and that there was limited evidence of coordinated clinical oversight to ensure that staff had the required skills and knowledge.
- And the third is person-centred care planning. The Review found that this was not evident in terms of Beverley feeling listened to and involved in her care decisions and there was insufficient attention to the view of the family.
The Review made recommendations under these three key areas and the Board is seeking assurance that multi-agency actions created from these recommendations are taken forward to reduce future risk.
So, what can you do to improve practice and reflect on the findings of Beverley’s Review? For this Review to be meaningful and help others like Beverley, please use the learning from the Review to reflect on how you can update your practice. To help you do this, please see our accompany learning briefing and the full Review on our website. The learning briefing includes questions for you and your colleagues to consider.
Also, there are other useful resources on our website which you can use, that are relevant to this Review. These are our Escalation and Resolution Protocol and, 4 other learning briefings and podcasts on:
- What is Safeguarding
- Making Safeguarding Personal
- Person-Centred Approaches
- and Multi-Agency Working and Communication
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 today. 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.