1.Background to the Safeguarding Adults Review (SAR)
1.1 A Safeguarding Adults Board (SAB) is required to undertake a Safeguarding Adults Review where an adult with care and support needs has died and the SAB knows or suspects that the death resulted from abuse or neglect, there is reasonable cause for concern about how the SAB, its members or others worked together to safeguard the adult
1.2 Alec died at Tiverton District Hospital on 5th April 2022. He had been admitted following a 999 call and attendance at his home by the ambulance service on April 1st. The cause of death was pneumonia following a stroke.
1.3 A referral for a SAR was made by Devon County Council Adult Social Care citing acts of omission and potential self-neglect. Safeguarding concerns had been received from a nurse on the hospital ward and the ambulance crew on the basis of self-neglect. The crew documented that in their view he had been living in squalor and that the house was not fit for human habitation. He was described as emaciated. On admission to hospital ward staff assessed that he was very frail.
1.4 During the 12 months prior to his death Alec had been treated as an outpatient at Tiverton District Hospital and seen on a number of occasions by staff at the Mid Devon Medical Practice. A doctor had visited him at home on the 30th March, two days prior to his admission to hospital.
1.5 On the basis of this information it was determined that a Safeguarding Adults Review should be commissioned because Alec had been a person in need of care and support, self-neglect may have been a factor in his death and it was suspected that agencies may not have worked together effectively to safeguard him.
2. Terms of Reference
2.1 The Terms of Reference for the SAR were to:
- Provide an account of Alec’s medical history and the treatment he received from medical practitioners in the 12 months prior to his death.
- Consider what knowledge those working with him had of the home circumstances in which he was living.
- Establish whether there were indicators of self-neglect and, if so, whether these were identified by practitioners and appropriate action taken, including assessment of Alec’s Mental Capacity.
- Assess the quality of inter-agency work and information sharing.
- Although Alec was estranged from his family, seek from family members their views about the care and treatment he received.
- Correlate any lessons emerging from the SAR with improvements recommended by the Torbay and Devon SAP thematic review of self-neglect.
3. Alec
3.1 Alec grew up in the north of England, one of a family of five children. His father was strict and had a quick temper but his upbringing was not unusual for the period. He joined the Army at the earliest opportunity and served his full time in the Royal Engineers. He rose to the rank of Staff Sergeant and was awarded the British Empire Medal. He did tours of duty in several countries and notably twice in Northern Ireland during the troubles where he was in charge of a small group clearing booby traps from buildings. The experience had a profound effect on him.
3.2 On discharge from the Army he set up a business involving furniture restoration and buying and selling second hand goods. This lasted for some years but once that failed his marriage broke down and over time he lost touch with his wife and two children. As early as the year 2000 he was showing early signs of mental health problems.
3.3 The last contact he had with his family was in 2004 when he and a girlfriend stayed with his niece and her family for six months. His use of alcohol and recreational drugs made life difficult, and Alec moved out. It was at that point that his niece lost contact with him again. In spite of various attempts to track him down over the years, she did not know of his whereabouts until she was contacted by one of his friends to say he had been admitted to hospital in 2022. A number of family members journeyed to visit him during his final days.
3.4 Alec’s niece and brother-in-law have participated in the review and their comments on the findings are set out in the full report.
4. Medical history
4.1 Alec experienced a range of health difficulties over a number of years. The following were noted when his medical history was taken on admission to hospital in April 2022.
| 1994 | Alcohol dependence syndrome; anxiety with depression; history of acute alcoholic hepatitis; alcohol withdrawal syndrome |
| 2001 | fracture of neck of femur |
| 2003 | fracture of fibula |
| 2014 | heart failure; chronic obstructive pulmonary disease (COPD); diverticulosis |
| 2015 | ischaemic heart disease, pacemaker fitted to manage severe heart failure. |
| 2019 | acute coronary syndrome |
| 2020 | pre-diabetes |
He was seen regularly for pacemaker and medication reviews.
4.2 Between December 2021 and March 2022 he was seen almost weekly by nursing staff at the Mid Devon Medical Practice and Tiverton District Hospital for treatment in respect of ulcerated legs, which was completed successfully in March. On the 30th March he was visited at home by a junior doctor [1] on placement at the Medical Practice following concerns expressed by a friend concerning deterioration in his breathing, twitchy hands and slight slurred speech. In consultation with his registered GP it was decided that his presentation was typical for deterioration of heart failure. The plan put in place was to order blood tests, increase bumetanide use (a diuretic to treat heart failure and oedema) to twice daily and refer back to cardiology. To review within one week but if he should deteriorate to admit to hospital for additional investigations. This was described as a safety net approach.
4.3 On April 1st he was admitted to hospital following a 999 call by his landlord with whom he lived. He was diagnosed with a late presenting stroke. He was described as extremely frail and cachectic by hospital staff. Alec died from pneumonia on 5th April.
[1] The doctor in question had qualified from medical school and was undertaking her second year of foundation training, i.e. practical experience in different settings. She had full registration with the GMC and a licence to practise. To differentiate her from Alec’s registered GP she is described as a junior doctor.
5. Self-neglect
5.1 Home circumstances
The conditions in which Alec lived were not initially recognised as an indicator of self-neglect. Two home visits were made in the months prior to his death. In December 2021 a community nurse had visited to undertake a doppler assessment of Alec’s leg condition. She met him and his landlord. Both men were unkempt. The house was crammed with boxes and possessions. Alec sat in a corner next to a heater so that it was not possible to complete the test. On 30th March 2022 the junior doctor noted that the living conditions were dirty and untidy with straw on the floor, surfaces covered in rubbish and mouldy food with flies everywhere. It was reported that he never washed. A friend, Alec and his landlord requested additional support, although stating that they would not want him to go into a care home.
When the Ambulance crew were called on April 1st they reported that the house was in squalor and in their opinion not fit for human habitation. They made a safeguarding referral and contacted the Fire Service to request a Home Safety visit. This was good practice.
5.2 Nutrition
Nutrition and weight loss had been a focus since 2015 when Alec’s pacemaker was fitted. He had been prescribed an oral nutrition supplement at different times but discontinued it at his own request. He was seen by his GP in February 2022 for a medication review at which he described himself as generally deconditioned. His GP did not notice that he looked dissimilar from previously. None of the nursing staff who treated his leg condition in the 3 months prior to his death recorded any concerns about his weight. In contrast the ambulance crew felt he was emaciated and at the hospital he was considered frail and cachectic having not eaten or been drinking sufficiently for an unknown period.
5.3 Mental capacity
Alec was deemed throughout to have mental capacity to share his views and make his own decisions about medical treatment until he was acutely unwell on 01/04/22 when the ambulance crew attended. A mental capacity assessment was undertaken and it was decided that he did not have mental capacity to consent to treatment at that time.
There are a number of occasions documented when he declined to take up or continue with treatment prescribed by medical staff. He did not maintain a healthy lifestyle and was sedentary most of the day. He wanted to minimise the need for medical intervention.
In contrast to this during the 12 months leading up to his death he regularly attended clinics to treat his leg ulcers, for the 6 monthly review of his pacemaker and his medication review. On the 30th March he and his friends recognised that he was becoming unable to look after himself and requested help for him.
6. Correlation with the thematic review of self-neglect
A number of features in the review are evident in respect of Alec.
6.1 “Practitioners accustomed or desensitised to poor standards of hygiene and extreme living conditions.”
Neither home visit outlined prompted a risk assessment of his home circumstances which would have been relevant not only to their impact upon Alec’s physical health but also the potential fire risk created by two men smoking and drinking in a cluttered property with much rubbish and straw lying around. The description of the property is consistent with level 2 and some elements of Level 3 of the Hoarding and Clutter Rating in the Self-Neglect and Hoarding toolkit on the Partnership’s website.
6.2 “Failure to identify and escalate concerns about deteriorating health and as a result insufficiently proactive about recognising the need for intervention.”
Alec did not have sufficient reserves to survive the impact of the stroke and subsequent pneumonia. Although he was seen on numerous occasions by practitioners between December 2021 and 30th March 2022, his increasing frailty and loss of weight were not identified until he was admitted to hospital.
His GP remains confident that the plan of treatment following the visit on 30/3 could have prevented any further deterioration in his heart condition and he would have followed up Alec the next week after receipt of the results of the blood tests ordered. The symptoms of a stroke recorded later on 01/04 were not present on this date.
Learning point
It is questioned whether a ‘safety net approach’ on 30/03 was sufficient in the circumstances. Although a friend had contacted the Practice and regularly drove Alec to appointments, it had not been established how far he or Alec’s landlord could be relied on to notice a deterioration in his condition and act upon any further concerns in a timely manner. On 01/04 the landlord was described by the ambulance service as a poor historian who could not give a clear history of events and by the hospital as not a protective factor. There had been a delay of nearly two hours between the point at which he had been advised to call 999 and when the phone call was actually received.
There was a case for a safeguarding referral to have been made on 30/3. It is also suggested that an early follow up visit by Alec’s registered GP could have allowed him to observe the home conditions directly and satisfy himself about the informal support Alec was receiving.
7. Summary and recommendations
7.1 Reflecting on the multiple health issues experienced by Alec for a number of years, the overall treatment and care he received both in the community and as an in-patient was good. For example, his pacemaker and medication reviews were undertaken regularly. The treatment to his leg ulcers was well coordinated and ultimately successful. In conversations with health practitioners I formed the view that Alec did not receive any less equitable treatment because of his social circumstances. However two key issues have emerged in respect of the events leading up to his death.
7.2 When the state of the property was observed during the home visits on 06/12/21 and 30/03/22 it was not regarded as a potential indicator of self-neglect. Nor was there concern that it may have posed a health and safety risk to Alec and his landlord.
7.3 Secondly Alec’s physical condition declined to the point at which he was considered emaciated and cachectic on 01/04/22. This deterioration and weakness had not been observed by any staff treating him in the weeks before but appear to have contributed to his inability to recover from the effects of the stroke that he suffered.
8. SAR Recommendations
The Torbay and Devon Safeguarding Adults Partnership (TDSAP) should ensure that multi-agency training on self-neglect improves staff understanding and confidence in assessing when dirty, unhygienic and/or cluttered home conditions should lead to a safeguarding referral. It should promote greater use of the Partnership’s self-neglect toolkit which is a helpful resource in this regard.
8.2 The TDSAP should ensure that multi-agency training also highlights the importance of risk assessments being undertaken in these circumstances and publicises the role that the Fire Service Home Safety team can play in attending to the safety of individuals who hoard.
8.3 The TDSAP should ensure that any training in respect of mental capacity increases practitioner awareness of the concept of ‘executive’ capacity and its specific relevance when assessing the mental capacity of individuals who self-neglect.
8.4 The Royal Devon University Healthcare NHS Foundation Trust reviews the E-learning offered to Foundation training doctors and community nursing staff in respect of self-neglect and continues to provide more detailed training to supplement this package.
8.5 The Integrated Care Board seeks assurance from the Mid-Devon Medical Practice that its action plan, following this review, has been fully implemented.
Barrie Crook
Independent Lead Reviewer
October 2023