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SAR Alec

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 are to:

1. Provide an account of Alec’s medical history and the treatment he received from medical practitioners in the 12 months prior to his death.

2. Consider what knowledge those working with him had of the home circumstances in which he was living.

3. 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.

4. Assess the quality of inter-agency work and information sharing.

5. Although Alec was estranged from his family, seek from family members their views about the care and treatment he received.

6. Correlate any lessons emerging from the SAR with improvements recommended by the Torbay and Devon SAP thematic review of self-neglect.

2.2 Methodology

The Review has been overseen by a multi-agency panel comprising representatives of the agencies but who themselves were not directly involved in Alec’s care.

The independent reviewer has analysed the Individual Management Reports, developed an integrated chronology and sought further information from agencies. There has been a particular focus upon key episodes such as the home visits made in 12/2021 and 03/2022 and observations made by staff who treated Alec in outpatients clinics in the intervening period.

Family members have been contacted to determine if they wish to participate in the Review and provide any relevant information.

Practitioners who had direct contact with Alec have had an opportunity to discuss their involvement with the independent reviewer.

In addition the following factors have been considered

  • Any impact of the covid pandemic
  • Staff understanding and training in respect of self-neglect
  • Making Safeguarding Personal
  • Professional curiosity and
  •  Any system issues which may have been a barrier to more effective engagement with Alec

It has not been possible to establish contact with the junior doctor who visited Alec in 03/2022, whilst Alec’s friend P, who is mentioned in the body of the report, declined contact with the author.

3. Agencies involved with Alec

3.1  The following agencies contributed Individual Management Reviews.

  • Royal Devon University Healthcare NHS Foundation Trust – treated Alec at the lower limb clinic and on admission to Tiverton hospital. Community nurse also visited his home.
  • Mid Devon Medical Practice – Alec was registered with the practice and treated by GPs and nursing staff
  • South Western Ambulance Service NHS Foundation Trust (SWAST) – only involvement was to attend following a 999 call and convey Alec to hospital
  •  Devon County Council Adult Social Care (ASC) – had no ongoing contact with Alec, but received the safeguarding referrals in April 2022

3.The Police, Fire Service and Environmental Health were also contacted but had no recent knowledge of Alec.

4. Family involvement

4.1 Alec was estranged from members of his family, including his two children, and had not been in contact with them for many years. A friend was initially listed as his next of kin in hospital records. However, on admission hospital staff were advised of a niece who was contacted. She then communicated with other members of his family.

4.2 One of his brothers was initially contacted concerning involvement in the SAR but declined, citing the fact that Alec had cut himself off from his family by the lifestyle he chose. However his niece has indicated that she wished to assist with the review and be advised of the outcome. The following background information concerning Alec’s life has been contributed by his niece and her father who was Alec’s brother-in-law.

5. Alec

5.1 Alec was born and brought up in the Oldham/Middleton area of what is now Greater Manchester. He was the third in a family of five children – one girl and four boys. His father was a Prison Officer, his mother a teacher. His father was strict and had a quick temper, but Alec’s upbringing was not unusual for the period. He joined the army at his earliest opportunity and thereafter never lived in the family home apart from some short periods on leave. He did keep in touch with his siblings though particularly his sister and older brother. Though after the death of his mother contact became more sporadic.

5.2 His niece remembers him as a kind and generous man. For two periods of time during her childhood her family and Alec’s family lived close to each other: first when he was stationed at the Gillingham barracks then, later, when he was attached to the Marines in Plymouth. It was during the latter period that Alec and his wife played a significant part in caring for his niece and nephew when their mother had serious mental health difficulties.

5.3 Alec was in the Royal Engineers and served his full time with them. He rose to the rank of Staff Sergeant and was awarded the British Empire Medal. Over the years, he did tours of duty in Germany, the Falkland Islands, several places in Great Britain and, notably, twice in Northern Island during the troubles when he was in charge of a small group who had the task of clearing booby traps from buildings. That experience had a profound effect on him. It is highly likely that he suffered from undiagnosed PTSD, which he self-medicated, as the years went by, with increasing amounts of alcohol and drugs. His trade in the army was as a pipeline engineer which expertise could have led to very profitable work when he left the forces. However, this would also have led to further periods of working away from the family which he did not want. Like many ex-servicemen and women, he found adjusting to civilian life difficult. 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 family. As early as the year two thousand he was showing early signs of mental health problems. He left Plymouth and began moving from place to place, without letting members of the family know where he was.

5.4 During this time in 2004/2005 he and a girlfriend turned up, unexpectedly and unannounced, at his niece’s house and lived with her and her family for the next six months. But this arrangement could not continue in the long run. The house was overcrowded, and his use of alcohol and recreational drugs made life difficult, and Alec moved out. It was at that point that she 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.

5.5A number of family members journeyed to visit Alec during his final days in hospital.

6. Medical history and account of the treatment he received from medical practitioners in the 12 months prior to his death

Provide an account of Alec’s medical history and if the treatment he received from medical practitioners in the 12 months prior to his death

6.1 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

6.3 During 2021 he was seen on two occasions for follow up appointments in respect of the pacemaker. On each occasion there had been no reported symptoms or cause for concern.

Medication reviews were undertaken by his General Practitioner (GP) in March 2021 by telephone because of covid and in person in February 2022.

Between December 2021 and March 2022 he was seen regularly by nursing staff at both the Mid Devon Medical Practice and the lower limb clinic of Tiverton District Hospital for treatment in respect of ulcerated legs. Nursing staff at the medical practice on one occasion advised him about leg elevation as he was said to ‘spend all his time in a chair.’ At one later appointment at the hospital he presented in a wheelchair, citing problems with his hip. The treatment to his legs was eventually successful and he was discharged from the clinic on the 23rd March 2022.

6.4 On the 30th March 2022 there was a telephone conversation between a doctor who was working at the practice under supervision[1] and P who described himself as Alec’s unofficial carer. It was reported that Alec’s breathing had deteriorated over the last few months and more so the previous week when he had twitchy hands and slight slurred speech. It was decided that a home visit was necessary and this was carried out by the junior doctor.

6.5 On examination Alec had a normal heart rate. He reported that his breathlessness had been worse during the last week and talked of exhaustion. He was able to talk in full sentences. The doctor was unable to measure oxygen saturation even on a warm hand. He had significant fluid retention in both legs. She noted that his 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. P visited twice a day to support Alec with shopping and medication. He, Alec and his landlord requested additional support, although stating that they would not want him to go into a care home.

On returning to the surgery the visit was discussed with Alec’s registered GP. It was concluded that given there was no fever but marked oedema and bilateral basal crackles, the presentation was typical for deterioration of heart failure and not pneumonia. 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.

This was communicated to P via telephone and Alec through text message. Contact details for Care Direct were given in respect of their request for increased help at home. (At the time this was the route by which a request for an adult social care assessment or a safeguarding referral could be made.)

6.6 On the 1st April at 11.30 Alec’s landlord came to the surgery and stated that Alec had deteriorated. At 11.45 he was given verbal advice (by a GP who was not Alec’s registered GP but had access to his medical notes) via the receptionist to call 999. A call was received by SWAST at 13.43. An ambulance crew attended. They assessed that Alec did not have mental capacity to consent to any treatment at that time and a best interests decision was taken to convey him to hospital. The crew reported that the house was in squalor and that in their opinion it was not fit for human habitation. A referral was made to the Fire Service for a Home Safety visit. Alec arrived at the Emergency Dept at the Royal Devon University Trust (RDUH) at 14.47. (The hospital IMR records time of arrival as 04.47 but it is assumed that this is a misprint.)

6.7 Once stable he was moved to a medical ward at the RDUH and treated there over the next four days. He was diagnosed with a late presenting stroke and was unable to communicate a history. (It is not clear when the stroke occurred, but by the time he arrived at the hospital the 4 hour optimal window had passed). He was noted to have right-sided hemiplegia, was extremely frail, cachetic[2] and very unkempt at triage. A decision was made to continue active treatment but to consider palliative care if this was not successful. At times he was alert but there was a deterioration in his breathing and advanced heart failure. He died on 05.04.22.  Hospital staff communicated his condition to friends regularly and then to his niece.

[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 hereon as a junior doctor.

[2] Cachexy or cachexia, a condition of profound physical weakness and wasting of the body associated with severe starvation or chronic disease (Chambers Dictionary)

7. What those working with him knew of the home circumstances in which he was living

Consider what knowledge those working with him had of the home circumstances in which is was living.

7.1 Alec lived with a friend who was also his landlord on a private basis. Visits to the address were made on two occasions.

7.2 On 06.12.21 a visit was made by a community nurse and healthcare assistant from Royal Devon University Healthcare Trust (Eastern) at the request of his GP Practice to undertake an Ankle Brachial Pressure Index (ABPI) examination to test for circulation in his legs and consider compression bandaging.

The IMR records that on arrival at the house the rooms were crammed with boxes and possessions. Alec sat in a corner next to a heater. It was hard to get to his legs and not possible to complete the test. Alec denied that he was housebound. Staff advised him that he needed an appointment at the practice surgery.

7.3 The second visit was that of the junior doctor from the mid Devon Medical Practice which is outlined in more detail in section 8.7. The Practice IMR indicates that no previous home visits had been required of Practice staff themselves that might have shed light on Alec’s living conditions since 2014.

7.4 The Fire Service had not visited the premises. Environmental Health has a record of a visit in 2011 when Alec was resident at the address, but nothing more recent.


8. Indicators of self-neglect and whether these were identified by practitioners and appropriate action taken, including assessment of Alec's Mental Capacity

Analysis and Findings

Establish whether there were indicators of self-neglect and, if so, whether these were identified by practitioners and appropriate action take, including assessment of Alec’s Mental Capacity

8.1 Self-neglect can involve the following indicators as set out in the Safeguarding Adults Partnership web-site [3]

“Lack of self-care to an extent that it threatens personal health and safety

Neglecting to care for one’s personal hygiene, health or surroundings

Inability to avoid harm as a result of self-neglect

Failure to seek help or access services to meet health and social care needs.”

8.2 The issue of self-neglect as a potential safeguarding concern was first raised by the Ambulance Service as a result of the visit on 1st April 2022. The primary reason for this was the squalid and unhealthy conditions of the premises. This led to a safeguarding referral which was received by the ASC safeguarding hub on the 5th April.

8.3 Ward staff at the hospital also completed a safeguarding referral on the 4th April based upon the Ambulance Service report but adding that Alec’s landlord was not considered to be a protective factor. The concern also stated that it was believed that Alec had not been eating or drinking enough for an unknown period. Staff observed that he looked underweight but he never became well enough for his weight to be measured. A photograph of the home conditions which had been taken by the Ambulance staff was also shared.

8.4 This recognition of potential self-neglect came at a relatively late stage in Alec’s life and too late to assist in respect of his recovery. The following section examines whether there had been similar or other indicators prior to this.

8.5 Home circumstances

Self-neglect was not considered during either of the two home visits outlined in section 7.

8.6 Whilst visiting on 06/12/21 the community nurse also met Alec’s friend/landlord. The friend was fully mobile but both men were unkempt. Alec advised her that he would not be staying long at the address but returning to Chudleigh.

Although the house was dirty and she could not carry out the ABPI test because of his surroundings, she did not consider indications of potential self-neglect. Alec was quite vocal. He stated that he did not need further help but was happy to continue to attend the surgery for treatment to his legs and his friend had a car to transport him.  She noticed that there was fresh food shopping in the house. She felt some concern about Alec’s mobility as the path to the house was very steep, but he did not consider this to be an issue. She was surprised to learn that he was still living at this address 4 months later.

On reflection she did not feel that the home circumstances were greatly different from many houses that she visits. As it was not Alec’s home and he stated he would be moving soon, she did not consider taking any further action other than recording her observations on the case record. These were not passed to the GP practice.

The Medical Practice has no record of an alternative address and as previously observed, Alec was also resident there in 2011. That same afternoon he had a telephone consultation with a GP concerning an allergic reaction to his medication. There was no reference to the earlier home visit. This suggests that at this time Alec and his landlord may have been reluctant to have visits to their home and that the reference to an alternative address may have been a distraction.

8.7 The second visit took place on the 30th March two days before Alec was admitted to hospital. When, on her return to the surgery the visit was discussed with Alec’s GP, the primary focus was on diagnosing Alec’s heart condition and taking steps to treat and ameliorate this. It was not unusual for Alec to have stopped taking prescribed medication and then suffer a relapse of some kind. There was no consideration of self-neglect at this point.

His GP acknowledges that the description given of the home circumstances was ‘grim’, although commenting that in rural Devon people are often not living in the same conditions as in the city.

8.8 Nutrition

Nutrition and weight loss had been a focus for health professionals in previous years. Alec was referred to a dietician in 2015 when he had the pacemaker fitted to manage severe heart failure. He was believed by the dietician to be at risk of malnutrition. His weight at that time was 50 kg. An oral nutrition supplement was begun. However after 6 months he declined this and further supplements.

In April 2019 he was only eating two small meals a day. His weight had reduced to 46 kg and in discussion with his GP a liquid supplement was prescribed.

In January 2020 his weight was 48 kg and his Body Mass Index was normal.

By March 2021 during a medication review consultation conducted by telephone during the Covid pandemic Alec advised that he was only occasionally using the nutrition supplement. After discussion with Alec this was stopped by his GP. Although his weight was not taken at this point, blood tests showed that his albumin level, a possible indicator of malnutrition, was normal.

Alec was seen at the lower limb clinic on six occasions in February and March 2022. The first assessment is described as holistic, recording a number of factors including eating and drinking. This assessment did not refer back to the descriptions of Alec’s home environment recorded by the community nurse nor any particular concerns about his weight or diet. Unfortunately staff who treated him were either unavailable or unable to remember him.

On 22.02.22 at his final medication review Alec reported that he felt tired and some breathlessness but ‘on discussion just felt he was generally getting deconditioned.’ The remainder of the review was concerned with his heart and Alec stated that the management of his leg condition was going well. His GP did not notice that he looked dissimilar from previously or make any observations about his weight.

In contrast, when the ambulance crew attended on 01/04 they thought he was ‘emaciated’. On admission he was described as ‘extremely frail and cachetic, extremely unkempt’.

8.9 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. These included the use of diuretics for heart disease, nutrition supplements and declining vaccinations. His niece recalled an occasion when he would not attend hospital for exploration of possible cancer of the oesophagus. He wanted to minimise the need for medical intervention. He did not maintain a healthy lifestyle, becoming dependent upon alcohol at an earlier point and continuing to smoke in spite of a diagnosis of COPD. His mobility reduced to the point where he was sedentary most of the day. He maintained to his GP that he had been teetotal since 2014. However the Ambulance Service found cans of lager at the property and his friend advised hospital staff that he drank alcohol.

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. He also reported reducing smoking by 50% in February 2021 but declined smoking cessation advice. He chose not to take his medication at times because he did not like the side effects.

His niece and a friend each related his outlook that as a former soldier he was not afraid to face death.

Aspects of emerging thinking in respect of ‘executive’ capacity would have been relevant to the assessment of Alec’s mental capacity. The thematic review of self-neglect has pointed towards the need to assess executive capacity in similar circumstances:

““Executive dysfunction, which can also be caused by a range of factors such as …………cardiovascular disease….or health conditions arising from long-term alcohol use, has been found to be a predominant factor that inhibits appropriate decision making and problem-solving”.[4]

“Association has also been made between frontal lobe dysfunction and severe domestic squalor…”

In respect of Alec the state of his living conditions did not become apparent until late on and there is no record that alcohol misuse was still severe, e.g. by his turning up for appointments while intoxicated. He did not always foresee or weigh up the potential impact upon his health of discontinuing his medication. Had he recovered from the stroke, executive capacity would have been a factor to keep under review in his care.

[3] ‘What is self neglect’
[4] Thematic review Appendix 3 “Mental capacity and executive function”.

9. The quality of inter-agency work and information sharing

Assess the quality of inter-agency work and information sharing

9.1 There are a number of instances of routine or good information sharing.

9.2 There was good information sharing by SWAST when the safeguarding referral was submitted to Adult Social Care and the hospital. A referral was also made to the Fire Service. Similarly hospital staff followed up the information provided by the ambulance crew, coupled with their observations of Alec’s physical condition when he was admitted.

9.3 Adult Social Care contacted the ward to advise them of the home surroundings so that this could have been taken into account had it been planned to discharge Alec.

9.4 There was regular report back to the GP from Alec’s pacemaker reviews. However his GP advised that he had received no feedback from either the lower leg clinic or the community nurse’s visit on 06/12/21.

10. Family members' views about the care and treatment he received

Although Alec was estranged from his family, seek from family members their views about the care and treatment he received.

10.1 Alec’s niece and brother-in-law have read and commented upon a draft report.  They feel that the report has highlighted most of the concerns that they would wish to raise about Alec’s care and treatment. They have emphasised the following issues.

10.2 They observe that both the community nurse and GP comment that the state of the house was no worse than other places they visit. They feel that more action should have been taken as a result of these visits.

10.3 They consider that there was no urgency in the action planned by the GP and junior doctor following the home visit on 30/3. They question (a) did Alec really deteriorate so much in less than 48 hours and (b) when the landlord attended the surgery on 01/04, why did the surgery not phone for an ambulance rather than leaving it to him to do.

10.4 Finally they believe that ‘behind a lot of the decisions people made they were thinking “This is a down and out living in atrocious conditions that he’s not doing anything about himself and there’s precious little we can do about it”’.

10.5 In relation to her contact with hospital staff Alec’s niece comments that she was treated with respect and kept informed. Staff were empathetic to the family situation and reassured her that they understood it had been Alec’s choice to leave his family and stay out of touch.

Correlate any lessons emerging from the SAR with improvements recommended by the Torbay and Devon SAP thematic review of self-neglect

11.1 The thematic review was commissioned to identify any recurring features of safeguarding practice that were evident in six cases of self-neglect which met the threshold for a SAR. A number of the features outlined in the review are evident in respect of Alec.

11.2 “Practitioners accustomed or desensitised to poor standards of hygiene and extreme living conditions.”

This characteristic was perhaps evident in the statements by the community nurse (8.6) and the GP (8.7). Each commented upon the frequency with which they encounter patients living in unhygienic or cluttered surroundings and the difficulties in weighing up whether any intervention is required.

Neither home visit prompted a risk assessment of the 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.

11.3 “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.

It is possible that this was because the various contacts he had with health professionals in his last three months were ‘episodic’. No one person observed him regularly over this time. His exposure to health professionals was on the basis of specific issues, treatment to his legs, a reaction to medication (by telephone), a medication review. The treatment to his legs was well coordinated but any deterioration in his overall physical health was not noticed.

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.

It is 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.

11.4 “Over-reliance on assumptions of mental capacity and the concept of lifestyle choices”

Alec was an independent person who did make his own lifestyle choices. His presentation to practitioners did not lead anyone to question whether he had mental capacity or to undertake a mental capacity assessment. In balancing the individual’s right to self-determination against their protection and safety, his propensity to make potentially unwise decisions about his own health was often respected. Consideration of executive capacity is discussed in section 8.9 and may have become more relevant when the nature of his home circumstances and lack of self-care were identified.

11.5 “Need for better understanding of self-neglect and its risks and of approaches that can produce positive outcomes”

In respect of the visit on 30/03, there was a case for a safeguarding referral to be made.

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; a lack of self-care was reported by his landlord; his physical condition was observed to be emaciated two days later, although this was not recorded at the time of the home visit.

Gaining consent from Alec would have been good practice, but it is likely that a safeguarding referral would anyway have led to an assessment of the additional care and support that had already been requested by Alec and his landlord.

All practitioners who spoke to the author stated that they had received safeguarding training, including reference to self-neglect, and knew how to make a safeguarding referral. Foundation level 2 doctors are expected to complete the E-learning level 2 safeguarding package provided by E-learning Health. This is also the case for community nursing staff, although staff who are band 6 or above are now required to complete level 3. It has not been possible to view the content of the self-neglect element of this training. The Royal Devon University Healthcare NHS Foundation Trust has begun to introduce some face to face training on self-neglect to supplement the E-learning.

The Medical Practice safeguarding policy has a brief section on self-neglect with links to more detailed information on the Partnership website, which includes the self-neglect toolkit. In his own reflections on this case Alec’s GP has indicated that in future he would ‘strongly consider making a referral on the same day as any information of self-neglect came to light having gathered additional first-hand information….and ideally consent would be obtained.’

The Medical Practice lead for safeguarding has indicated that following completion of the SAR he will ensure that self-neglect will form part of the training for all practice staff and of the induction training for trainee doctors.


12. Summary and recommendations

12.1 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.

12.2 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.

12.3 Secondly Alec’s physical condition declined to the point at which he was considered emaciated and cachetic 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.

12.4 The findings of this SAR are consistent with the evidence gathered by the authors of the thematic review into self-neglect. Two of the recommendations from that review are particularly pertinent, namely that Torbay and Devon Safeguarding Adults Partnership (TDSAP):

  • audits the use of its guidance on self-neglect, escalation, adult safeguarding concerns, and multi-agency meetings across the Partnership. And
  • provides multi-agency training on self-neglect, on referrals of adult safeguarding concerns, and on legal literacy, particularly with respect to safeguarding, mental capacity, consent and information-sharing.

The complementary recommendations from this SAR are that:

12.5 The TDSAP should ensure that the 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.

12.6 The TDSAP should ensure that the 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.

12.7 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.

In addition it is recommended that:

12.8 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.

12.9 The Integrated Care Board seeks assurance from the Mid-Devon Medical Practice that its action plan following this review has been fully implemented.

The author

Barrie Crook is a coach and consultant who is independent of the organisations involved in this review.

From 2015-2021 he was the Chair of the Dorset and Bournemouth, Christchurch and Poole Safeguarding Adults Boards. Prior to this he was the Chief Executive of Hampshire Probation Trust.

He now practises as an independent lead reviewer of Safeguarding Adult Reviews and Domestic Homicide Reviews.

October 2023.


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