Thank you for listening to this short podcast on behalf of the West Sussex Safeguarding Adults Board. It is about the Safeguarding Adult Review for Robert.
Robert’s brother contributed significantly to the Review, providing a rich and meaningful understanding of Robert’s personality, life experiences and quality of life so, I would, firstly, like to share some of this information with you.
Robert was a 61-year-old man who enjoyed arts and crafts, shopping, visiting cafes, attending church, social events and holidays. Robert’s care team described him was a lively character who could make anyone smile.
Robert was registered blind, he was mostly non-verbal, had a moderate to severe learning disability and a diagnosis of schizophrenia. Robert also, had recurrent depression and issues relating to severe constipation and a recurrent volvulus resulting in hospital admissions.
Robert lived in a care home for over 10 years, his brother reflects that Robert had been very happy during his time there. However, during his last 18 months there was something different in the leadership of the home which he felt was exacerbated by COVID and he had a lack of confidence in the care home at that time. In the last few years Robert also experienced a number of safeguarding concerns.
6 weeks before he died, Robert moved to a different care home, but was soon admitted to hospital where he sadly died. The cause of Robert’s death was inanition, which is an exhausted state due to prolonged under nutrition or starvation, and a right fractured neck of femur. Following Robert’s death, a Learning Disabilities Mortality Review found the need for improved co-ordination of care and providing holistic support.
Our 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. It identified four key findings in relation to; health oversight and coordination, person centred planning, safeguarding responses and staff skills and knowledge. The Review also found areas of good practice which were the following:
- the learning disabilities (LD) team worked well within the multi-disciplinary team
- there were comprehensive psychiatry reviews
- there was holistic application of the Mental Capacity Act
- there were some holistic and person-centred wellbeing reviews
- there was regular contact with family members and;
- there was a high standard of safeguarding concerns from the learning disability team.
The Review made recommendations under five key areas. These were; multi-agency working, safeguarding, workforce skills and knowledge and, communication. 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 Robert, 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
- Our MSP Learning Briefing & Podcast
- Our Person-Centred Approaches Learning Briefing & Podcast
- Our Information sharing guide & protocol, and
- The Pan-Sussex Safeguarding Policy and Procedures
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 real difference for those who we are supporting in West Sussex.