SAR Joe

1. Introduction

This report covers the findings and recommendations of the Safeguarding Adults Review, undertaken on behalf of the Torbay and Devon Safeguarding Adults Partnership (TDSAP), relating to the care of an adult (referred to as Joe throughout this report to preserve his anonymity). The Safeguarding Adults Review (SAR) is not intended to attribute blame, but to learn lessons from the circumstances and make recommendations for change that will help to improve the future safeguarding and wellbeing of adults at risk in similar circumstances, in the future.

The review was conducted in the light of the following legislation: Section 44, Care Act (2014) Safeguarding Adults Reviews. The purpose of a Safeguarding Adults Review is described very clearly in the statutory guidance as to ‘promote effective learning and improvement action to prevent future deaths or serious harm occurring again’.

“SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again. Its purpose is not to hold any individual or organisation to account”[1]

[1] https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance#safeguarding-1

1.1 Why was this case chosen to be reviewed?

There is evidence of growing numbers of people experiencing homelessness, who increasingly experience abuse, exploitation and neglect, escalating health and care needs, and premature mortality.

In response to rising concerns, media publicity and the increased visibility of homelessness as an issue across the country, the Government released its Rough Sleeping Strategy 2018)[1]. This has raised the profile of people sleeping rough and the Government’s commitment to end this by 2027. The strategy makes an explicit link between homelessness and adult safeguarding in respect of individuals who die whilst sleeping on the streets. The strategy states …

“We agree with the Advisory Panel, who were clear that Safeguarding Adults Reviews are powerful tools, which unfortunately are rarely used in the case of people who sleep rough. We will work with Safeguarding Adults Boards to ensure that Safeguarding Adults Reviews are conducted when a person who sleeps rough dies or is seriously harmed because of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. Lessons learned from these reviews will inform improvements in local systems and services”[2].

Joe was referred to the TDSAP for consideration of a SAR by the Homeless Strategy and Partnership Lead for Exeter City Council (ECC) in January 2024 and the TDSAP SAR Core Group agreed that the grounds for the SAR were mandatory, under S44.1 and S44.2 of The Care Act (2014)[3]. This was based on initial information indicating possible neglect and a reasonable cause for concern about how partner agencies worked together to safeguard the adult, including the appropriate sharing of information, with Joe being discharged homeless from hospital and at risk of harm’.

Why focus on ‘Inclusion Social Care’ for homelessness?

The estimated number of deaths among people experiencing homelessness increased by over 50% from 2013 to 2021. Among men, mean age at death is 45.4 years; among women it is 43.2years (ONS figures for England and Wales)[4].

[1] https://www.gov.uk/government/publications/the-rough-sleeping-strategy

[2] https://www.gov.uk/government/publications/the-rough-sleeping-strategy

[3] https://www.legislation.gov.uk/ukpga/2014/23/section/44

[4]https://kclpure.kcl.ac.uk/ws/portalfiles/portal/238415173/Social_work_role_within_responses_to_Homelessness_-_REPORT_2023.pdf

1.2 Summary of the circumstances

Joe was 43 years old when he died. His body was discovered in the stairwell of a carpark in Exeter City Centre. The autopsy identified that Joe had ingested heroin and cocaine prior to his death. The level of morphine in his blood stream was below that usually associated with morphine toxicity; however, it was noted that:

‘Morphine is a central nervous system depressant and may cause fatal cardiorespiratory depression; however, this is dependent on Joe’s tolerance to opiates at the time of administration. However, opiate toxicity cannot be ruled out, given his tolerance is unknown and he had pre-existing cardiac pathology. In my opinion, the direct cause of death is ischaemic heart disease with morphine toxicity being a contributing factor’.[1]

Joe was of White UK ethnicity and had been born locally in Devon, however there was little information available to the review of his social history or family circumstances. Joe had exhibited signs of mental health problems, including depression and psychosis, since 1998 and reported heroin misuse in 1999 to his GP. He experienced multiple hospital admissions in the following years related to both drug overdoses and psychotic episodes, including diagnoses of schizophrenia or possible drug-induced psychosis between 2003 and 2004. Joe’s mental health deteriorated at times over the years with repeated admissions under the Mental Health Act (1983) (MHA), with episodes of self-harm and substance misuse. Joe’s full housing history was not well known to the review, but he had a significant history of homelessness and rough sleeping in and around Exeter.

Joe had resided in a supported accommodation project, for people experiencing homelessness, since 2017 although his mental health and substance misuse problems during this time were felt to present challenges which became beyond the scope of the provider to manage. Joe’s mental health showed significant deterioration during 2023, with frequent reports of psychotic symptoms, auditory hallucinations, paranoia and increasingly erratic behaviour.

In July 2023, Joe was detained under Section 2 of the Mental Health Act (1983), due to a relapse in his mental state, associated risks and severe self-neglect. Psychiatric assessments confirmed active psychosis and his lack of insight, recommending inpatient treatment and sustained medication, including depot antipsychotics. During his hospital stay, Joe exhibited periods of agitation and non-compliance, including several absconding episodes whereby he would return to the ward intoxicated. His difficulties engaging with assessments and ongoing substance misuse complicated attempted discharge arrangements. Joe was discharged street homeless from hospital on the 26th October 2023, with a temporary B&B hotel stay funded as an emergency option by his mother. Housing assessments were attempted but were unsuccessful and he sadly died 5 days after his discharge.

[1] Post Mortem Report. Dr Ramzi Rajab 2023

1.3 Timeframe, Terms of Reference, methodology and scope

A Safeguarding Adults Review Panel was established to work with the Lead Reviewer, representing the key agencies involved and all submitted Individual Management Review reports (IMRs) of their contacts with Joe. An integrated chronology was produced by the Lead Reviewer, focusing on multi agency involvement during the period of a year prior to his death in October 2023, but also including key events outside of this timeframe. This integrated chronology was then further analysed by the Lead Reviewer with follow up meetings where necessary with individual agency’s IMR authors.

1.3.1. Terms of Reference

1. Did the involvement of partner organisations with Joe indicate what currently either supports or hinders effective practice, as set out in the ADASS Briefing on Adult Safeguarding and Homelessness, for the following domains:

Direct practice with Joe, including how well the challenges of meeting statutory duties are being addressed for both the assessment of care and support needs and undertaking safeguarding enquiries, (as set out in the Care Act 2014) for people experiencing Multiple Exclusion Homelessness.

Multi agency working around Joe, focusing on how well partner agencies worked together to address his needs related to his mental health, physical health and substance misuse during the period subject to review?

2. For people at risk of Multiple Exclusion Homelessness, what learning can be identified from Joe’s circumstances for the partner organisations, regarding provision and accessibility of sufficient and suitable accommodation, in line with relevant Housing duties and responsibilities.

Multiple Exclusion Homelessness (MEH) is defined as “extreme marginalisation that includes childhood trauma, physical and mental ill-health, substance misuse and experiences of institutional care. Adverse experiences in childhood can include abuse and neglect, domestic violence, poverty and parental mental illness or substance misuse. For many of those who are rough sleeping, homelessness is a long-term experience and associated with tri-morbidity (impairments arising from a combination of mental ill-health, physical ill-health and drug and/or alcohol misuse) and premature mortality.[1] At the time of writing this terminology was not in use for partner agencies in Devon.

[1] Mason, K., Cornes, M., Dobson, R., Meakin, A., Ornelas, B. and Whiteford, M. (2017/18) ‘Multiple exclusion homelessness and adult social care in England: exploring the challenges through a researcher-practitioner partnership.’ Research, Policy and Planning, 33 (1), 3-14.

1.4 Agencies represented on the SAR Panel

Bournemouth Churches Housing Association (BCHA) – provider of supported accommodation for homeless adults

Charity – providing services including a day centre to homeless people in Exeter

Devon & Cornwall Police

NHS Devon – commissioner of healthcare provision in Devon

Devon Partnership NHS Trust – provider of mental health services in Devon

Exeter City Council – District Council, provider of housing duties

Inclusion Health Community Interest Company, Clocktower Surgery – provider of medical care to homeless people in Exeter.

Public Health Devon County Council – Health protection services

Integrated Adult Social Care, Devon County Council – Provision of adult social care (Care Act (2014) responsibilities including safeguarding adults.

1.5 Reviewing expertise and independence

A Lead Reviewer (Mick Haggar) was appointed by the SAB Chair to undertake the SAR and is the author of this report. Mick is a registered Social Worker, has worked in safeguarding adults, mental health and homelessness for over 25 years and is an experienced reviewer, having completed over 30 reviews. This report has been completed based on submissions of individual agency documents, conversations with individuals, reports, and chronologies from the partner agencies (outlined above).

1.6 Involvement of family members

The views and contributions of family members are an important aspect of the SAR process, both to inform them of the review, and to take account of their first-hand experience of services provided to them/their relative. Both the TDSAP and practitioners who knew Joe contacted his mother to inform her of the SAR and invite her comments, however, to date she has declined to be involved. In view of this, the report does not include the family perspective on care provided to Joe. This is acknowledged as a significant omission in the SAR process.

2. Narrative summary of key events in Joe’s circumstances

2.1 History and summary of events prior to the period subject to review

In 1998, aged 18, Joe reported depression to his GP, the following year was admitted to hospital for treatment following an overdose of heroin. In the following 20 years he reported misuse of other drugs, including ecstasy, cannabis and cocaine. He had further hospital admissions for drug overdoses and psychotic episodes, including formal admissions under both Section 2 and Section 3 of the Mental Health Act (1983). Joe was diagnosed with schizophrenia and had attempted suicide in 2014. He spent significant periods street homeless until accommodated in a homeless supported accommodation project in 2017, where he remained until 2023. Joe considered this supported accommodation project as his permanent home and did not want to leave. His last contact with mental health services was also in 2017, prior to the re-referral in 2022.

2019 – Staff raised concerns that Joe accessed the local homelessness day centre daily for food as he could not prepare meals for himself. The assessment by day centre staff was that Joe was very limited in terms of his cooking skills and at risk of self-neglect and malnourishment if he did not continue to access the day centre. On balance it was decided that it was safer for Joe to continue to access day centre for 2 daily meals Monday – Friday. Joe’s behaviour at the day centre was polite, quiet and well-mannered.

2020 – Due to Covid restrictions the day centre reduced the number of clients coming into the day centre and began to provide ‘food outreach’ (taking breakfast and lunch to clients in open air rather than in the day centre). Joe was ‘targeted’ to find and provide food to on outreach, due to the ongoing concerns around his ability to maintain adequate food and fluid intake by himself, the outreach team were aware that Joe was using cannabis.

2021 – Joe was confirmed on a list of those referred for consideration for Housing First or NSAP [Next Stage Accommodation Programme – Government funding for move on accommodation for those with a history of homelessness]. Joe was identified as ‘Group 3’ out of a long list – so deemed very unlikely to be offered a flat via this process. Joe was reported to police for shouting in the street at members of the public, making gestures to kick them when they did not give him money. He was arrested for a public order offence, charged with being drunk and disorderly and initially diverted through the pathfinder scheme[1]. Joe failed to engage in this process so was then sent a summons for court for the original offence.

Olanzapine 10mg[2] (an antipsychotic medicine) was prescribed, via the Clocktower surgery (CTS). Joe had been on Olanzapine from 2012 to mid 2014 (changed to depo when in hospital). It was restarted in June 2016 by his previous GP surgery after leaving prison – he had requested it stating he was no longer on depo. In September 2016 he registered at CTS and was continued on Olanzapine. From then until May 2021, Joe was reviewed regularly by GPs; he often attended each month when his prescription was due or else requested a repeat. The dose was adjusted at times. He had been opened to the Community Mental Health Team in 2018 but closed for non-engagement. Joe was offered a referral to mental health services on several occasions but he declined. He was advised of the need for physical health monitoring and this had last been done in June 2017. Following that he declined or avoided monitoring.

Olanzapine was continued to May 2021 – at that point he was asked to attend for review as he had not been seen for some time, but Joe did not attend and did not request it again. Between then and September 2021 the GPs liaised with his supported living provider and made assertive attempts to engage Joe (including visits, offering appointments at quiet times, offering drop-in). In September 2021 Joe requested Olanzapine and it was prescribed; further attempts were made to see him without success. He did not request it again.

2022 – Exeter City Council (ECC) Housing Department were contacted by the supported accommodation project regarding Joe’s rent arrears as there was a risk of possible eviction, and ECC agreed to pay off his arrears, to avoid the risk of homelessness. Joe’s mental and physical health had deteriorated, with concerns of exploitation by other people from the Homeless Community. He was given notice to quit by the supported accommodation project and a Duty To Refer[3] (DTR 1) to ECC was completed. A DTR is a statutory responsibility on public authorities to refer people considered to be at risk of homelessness to the local housing authority services to prevent this risk of homelessness.

A safeguarding adult concern (1) was raised to Adult Social Care in August by the supported accommodation project staff, regarding the risks of eviction and financial exploitation, which was closed without further information gathering and no attempts were made to speak to Joe.

Another safeguarding adult concern (2) was raised later in August by the supported accommodation project staff to Adult Social Care, due to the repeated concerns relating to his vulnerability to financial exploitation by another resident who had his bank card.

Joe’s mental health was noted to be deteriorating; he was at risk of eviction and refusing support. This safeguarding concern was closed, with a plan to combine this with a subsequent safeguarding concern (3), this was not actually done.

The safeguarding adult concern 3 was received in early September, it raised Joe’s declining mental health, self-neglect and risks of eviction. This was then closed by the Adult Social Care Social Worker at the Section 42 (1) stage. This is the triage stage at which the local authority consider whether 3 criteria have been met to progress to a statutory Section 42 (2) enquiry. This was reportedly based on the views of three professionals who had met Joe. There were no further details of these individuals, nor their views as to why this concern should not be progressed. Instead of progressing work under safeguarding procedures, a referral was reportedly made to the GP to request a visit to assess Joe, although CTS have no record of this request from a Social Worker for a visit. In August 2022 a GP had visited Joe along with a Community Psychiatric Nurse (PCN) from the Homelessness Community Mental Health Team (HCMHT). In September 2022 Joe’s GP spoke to a Social Worker and agreed that mental health services needed to progress this. On 20th Sep 2022 the GP attended a multi-agency meeting with the CPN and a worker from his supported accommodation, the plan from this was for a joint visit from a CPN and a benefits advisor.

Reflection Point 1. There were 3 safeguarding concerns raised to Adult Social Care within a short space of time due to escalating risks for Joe, however these were all closed by Adult Social Care without sufficient action taken to establish whether there was a duty under Srction 42 (2) to undertake an enquiry into these issues.

The basis of concluding that the 3-stage criteria had not been met by these concerns for this duty was not clearly recorded. Had a safeguarding enquiry been undertaken there could have been an opportunity to both assess and attempt to mitigate these risks before they further escalated, (which ultimately resulting in his detention under the Mental Health Act (1983) and eviction from the supported accommodation project). This was therefore a missed opportunity to prevent harm.

KPE 1 October 2022-June 2023

Referred to Homelessness Mental Health Services and supported accommodation project staff continue to raise concerns about risks they were unable to manage using both a Notice to Quit and safeguarding adult concerns.

October – December 2022 – An application was submitted for Personal Independence Payments[4] (PIP) to be restarted, with support from the welfare service at the day centre, however the subsequent health questionnaire was not completed by Joe and the Department for Work and Pensions (DWP) identified additional support was required for this.A discussion in the Multi-Disciplinary Team (MDT) under the Outreach List of the HCMHT showed that a visit had been previously attempted, but Joe was not home, with planning then made for another visit.Supported accommodation project staff had made more requests to DCC for assessment of his mental health, social care and housing support needs, to avoid eviction and street homelessness, due to increasing concerns about his poor mental health, lack of capacity and non-engagement.

January 2023 – Joe was seen by a nurse from the Clocktower surgery[5] at the supported accommodation project for dressings on a wound on his shoulder following concerns from supported accommodation project staff who had phoned an ambulance. The paramedics advised him to go to hospital, but he declined. Joe was then seen by a GP, who felt Joe was guarded, paranoid and was concerned that Joe had been incorrectly injecting heroin into his muscle. Joe reported his ‘wound had been done’ by an invisible friend and the GP made a referral to the Approved Mental Health Practitioner (AMHP)[6]Team for a Mental Health Act (1983) assessment. The AMHP Team liaised with the HCMHT, but he had not engaged with them. He was visited by a Consultant Psychiatrist and Community Psychiatric Nurse (CPN) from the HCMHT and Joe engaged for 20 minutes; he described the voices he hears. He agreed to work with HCMHT about his mental health and to have dressings on his shoulder wound. Due to this a formal Mental Health Act Assessment was no longer required, and he was allocated to the CPN from the HCMHT, who subsequently become his Care Coordinator.

Reflection Point 2. There were issues with Joe’s subsequent engagement however at this stage he did agree to work with mental health services and there was an opportunity to also assess his social care needs through completion of a Care Act assessment.

The Department for Work and Pensions (DWP) contacted Joe’s support worker and completed the required PIP health questionnaire, resulting in Joe being awarded enhanced rate of both Mobility and Daily living needs, backdated to the original claim in October 2022. He was paid over £2,000 into his bank account and his support worker was notified to ensure he was able to manage this large payment. Another safeguarding adults concern (4) was received from the supported accommodation project, but this was not accepted nor recorded as a safeguarding concern by DCC. It was referenced within case recording notes, however the reason for the decision that it did not meet Section 42 (1) criteria was based on his Care Coordinator assessing capacity for understanding his care and support needs and the concern was forwarded to them. His vulnerability to financial exploitation following the above PIP award, was known but did not appear to have been considered or addressed.

March 2023 – The ECC Rough Sleeper Coordinator sent an email to the Access to Accommodation panel chair (A2A, a multi-agency panel to address risk of homelessness), as Joe’s physical and mental health were deteriorating, requiring specialist MH accommodation. Also, staff were requesting attendance of DPT at A2A, due to the significant mental health issues. The A2A minutes/action showed that Joe needed to move on from the supported accommodation project. Joe also applied to the DWP for a budgeting loan and was awarded £350, it was not known what this was for, nor what Joe spent this on.

May 2023 – There was a further visit by a nurse from the GP surgery, Joe’s arm wound remained healed. However, his neighbours complained of lots of shouting by Joe at night (this was thought to be in response to auditory hallucinations), and the supported accommodation project were reviewing the possibility of Joe moving on. He continued to be seen on the street and provided with food by the day centre’s food outreach team, albeit more intermittently.

KPE 2. June 2023-July 2023

Decline in Joe’s mental health, another safeguarding referral and attempts made to engage him, prior to a formal MHA assessment at the supported accommodation project.

June 2023 – Supported accommodation project staff attended Joe’s room due to loud shouting and arguing. Joe had started moving items out of his room, believing urine was coming through the window from above. Joe was seen in passing by a nurse from the Clocktower surgery. This was his last contact with any clinician from the GP practice. Supported accommodation project staff again responded to loud arguing from Joe’s room. He was shouting but alone and stopped when asked. A request was made to DPT for an Multi – Disciplinary meeting. Another safeguarding adults concern (5) was completed by supported accommodation project staff due to the inability to manage Joe’s deteriorating mental health, further safeguarding concerns, and imminent eviction. A meeting was rescheduled for July, as this had previously been cancelled by HCMHT, although clinicians from Clocktower surgery were unable to attend on the revised date.

July 2023 – Joe started to engage and agreed to meet a Social Worker from DCC for an assessment with further correspondence from supported accommodation project staff requesting that a Social Care Assessment be set up as Joe was currently motivated to engage and had set up a payment plan for service charges and rent arrears.

The safeguarding adult concern (5) was reviewed by a Social Worker from the Devon County Council (DCC) Safeguarding Adults Hub, which included that Joe was a victim of verbal threats by other residents in his building. Joe believed that others were pouring water through his vents and had erratic behaviour. The supported accommodation project staff continued to provide welfare checks to ensure there was no-one in his room. They removed two residents from the area outside of Joe’s room; however, this was on a temporary basis due to them both living in the same cluster as Joe. Joe had been the victim of verbal threats to kill him from two residents and threats of harm. This safeguarding adults concern (5) proceeded to Section 42 (2) safeguarding enquiry and “caused out by DCC to Devon Partnership Trust (DPT)” as part of the Section 75 agreement between DCC and DPT[7].It was RAG rated as red for risks, the outcome of this Section 42 enquiry was later summarised retrospectively from DPT records, which were not returned to DCC until January 2024 (3 months after Joe had been found deceased).

The “Safeguarding Enquiry Report” was not an original document and not based on actions specifically arising from any enquiry actions undertaken to investigate the allegations. The report consisted of previous notes which had been copied and pasted into the form. These recorded other actions which were undertaken at the time, including the plans for Joe’s Mental Health Act (1983) assessment and an MDT meeting, which were set up at the request of the supported accommodation project. There was no actual enquiry made by DPT into the issues raised on this safeguarding concern. Immediate risks to Joe were resolved through the MHA route (as Joe was detained), although the underlying issues of abuse at the project prior to this, were not addressed.

The multi-disciplinary meeting (MDT), which had been requested by supported accommodation project staff, was held to discuss move on plans for Joeand next steps for his care. The meeting involved his Care Coordinator from HCMHT (DPT), Mental Health Social Work (DCC) and supported accommodation project housing staff. It was held on the same day that the above Section 42 (2) Enquiry was caused out to DPT to undertake. A further unsuccessful attempt was made by the DCC Social Worker to meet Joe for an assessment and the Social Worker felt that although he would benefit from support, Joe was liable to be seen as unsuitable for supported housing, due to his continued lack of engagement. Risks relating to Joe’s poor personal care and deteriorating mental state were discussed with the Social Worker by the supported accommodation project staff. Joe was reported to be thin, was not eating well and his living conditions were a fire risk because of the number of belongings he had hoarded.

Due to these risks and lack of engagement with both DPT and DCC it was agreed at the MDT meeting that a formal Mental Health Act (1983) assessment was now required. However, this was initially rejected based on there being conflicting information about Joe’s engagement levels. The AMHP team requested that Joe was seen by his consultant first for an opinion and he was then visited at supported accommodation project by an Associate Specialist Dr. Joe refused to see him, but the Dr did summarise his views that a Mental Health Act assessment was required.

“This should not be with a view to just a few days of observation or medication with premature discharge back to his same situation. He needs a sustained period of treatment, preferably being stabilised on depot antipsychotic medication and then proper multiagency planning for appropriate mental-health supported accommodation that can manage his risk safely and sustain his reintegration into the community. Any other course of action would to my mind constitute neglect of his urgent needs”.

Reflection Point 3. This recommendation appears to have been entirely appropriate on the part of the Dr and would have given Joe a much better chance to engage with services, once his psychosis had been treated and to have a planned discharge to suitable specialist supported housing. Unfortunately, this was not done, resulting in a missed opportunity.

After several attempts, Joe was assessed and detained on the 28^th July 2023, under Section 2 of the Mental Health Act (1983), due to drug induced psychosis. Also, a Duty to Refer (DTR. 2.) was made by supported accommodation project staff to ECC, as Joe was in danger of becoming homeless, due to their pending eviction for his rent arrears. In response to this ECC agreed to pay off his outstanding arrears to prevent this eviction (an example of positive practice). Supported accommodation project staff also made a police report over the conduct of other residents to Joe regarding an incident in which Joe was threatened. The crime was later filed with no further action as Joe did not want to engage.

KPE 3. August 2023- 25^th October 2023

Joe’s admission, treatment and plans for his discharge from Hospital. License[8] revoked at supported accommodation project, making Joe homeless during his admission.

August 2023. On admission Joe was clearly unwell, pacing, shouting, and responding to unseen stimuli. He was irritable and delusional but accepted PRN medication (when required – usually prescribed on a short term or intermittent basis). Within 10 days in hospital Joe was described as mostly settled and pleasant but had some shouting episodes. He was eating, taking medication and using leave appropriately.

Meanwhile, supported accommodation project staff requested another MDT to plan for his housing needs, upon discharge, with his Social Worker (who wanted to wait until Joe was stable and substance-free before conducting a Social Care Assessment). This assessment was attempted again unsuccessfully the following week, Joe still refused to engage, resulting in the Social Worker planning one further attempt prior to planning to close the referral.

Reflection Point 4. This illustrates the complexities surrounding the decision of when to attempt assessments of social care needs for people who have been detained under MHA (1983) in mental health inpatient units, as these assessments need to be completed when the person is sufficiently well to accurately reflect what those needs will be following treatment when the person is ready to be discharged. However, waiting for this point to be reached may result in the person being discharged prior to this assessment being completed, due to pressure on hospital beds resulting in the person being discharged prior to a social care assessment of needs and prior to a suitable service being found to meet those needs, as subsequently happened in Joe’s case.

His license at the supported accommodation project was removed at this time, due to Joe’s high care and support needs and a further DTR (3.) was completed, with a risk assessment, this was not initially received by the Housing Triage Officer. It was followed up by the hospital discharge coordinator, having been re-sent from the ward (DTR.4). This was then accepted by ECC and allocated to a Housing Case worker.

At another A2A meeting Joe was again discussed, the risk of street discharge was again noted, and strong recommendations were made for supported mental health accommodation. Concerns were raised about Joe’s inability to engage and the risk of homelessness, with an outcome that the Social Worker planned another assessment attempt and requested that Joe’s case was kept open by Housing until the assessment was completed, as Joe may not have eligible care and support needs. The Housing Case Worker did liaise with the discharge coordinator at the ward regarding his priority need and housing options, which were limited at this stage due to his non-engagement.

Reflection Point 5. It was not clear what was done to engage Joe in this process, nor why this failed. It was subsequently reported to the Lead Reviewer that Joe continued to inappropriately consider the supported accommodation project his permanent home and would avoid an opportunity for any alternative accommodation to be explored with him. The extent to which this belief was related to his poor mental health was not clear at the time, but it was clearly a significant obstacle to engagement with him, which was never successfully addressed.

At the end of the month a further MHA assessment was undertaken on the ward with Joe detained under Section 3[9] of the Mental Health Act (1983). Shortly after which Joe went missing during Section 17[10] leave (this is leave from the ward having been agreed by his Responsible Clinician) and was returned by police later that night after contact from supported accommodation project staff as Joe had turned up there again. Joe appeared very confused on arrival at the supported accommodation project, in a poor appearance smelling of faeces and vomit, his clothes were the same as when he had left the supported accommodation project a month earlier and he looked like he was under the influence of drugs.

He then left the supported accommodation project and later that night was seen with a couple of individuals from the homeless community being taken to the cash point. After his return to the ward by the police Joe admitted to taking drugs (heroin and crack) while he went missing. This was noted also on the minutes of an A2A meeting the next week where he had been nominated to the ‘Adult Social Care Panel’ for funding for supported accommodation. There was a note of concern by the HCMHT worker about where Joe could be discharged to and a plan to discuss options with his DCC Social Worker.

September 2023 – At the beginning of the month there was further email correspondence from the hospital discharge coordinator with the Housing Officer about Joe’s accommodation and support needs, due to the Social Worker still being unable to engage with him for an assessment. His refusal was thought to be unrelated to his mental health, and it was acknowledged in this email he was at high risk of overdosing from drugs on discharge (which is what subsequently happened).

Joe was noted to be using drugs and alcohol on the ward and there were plans made for his discharge from the hospital, despite his lack of engagement. As the Duty to Refer (3.) had been completed, a request was made for an update from his Housing Officer and if he continued to decline support a request to notify the Street Homeless Outreach Team. Joe then went missing from the ward again and the police were notified once more, with ward staff stating he had left the ward to go and buy drugs. He later returned of his own accord, having turned up again at the supported accommodation project. His Section 17 leave was then cancelled. He arrived on the ward with a crack pipe and was reported to be dirty and dishevelled.

The next day a Section 117[11] aftercare planning meeting was held during a ward round, where it was acknowledged that Joe was currently homeless and therefore any discharge would be a homeless discharge. It was recognised that DCC Integrated Adult Social Care had not been able to engage Joe which was preventing them from being able to find him accommodation. The Responsible Clinician considered risks during the meeting and recognised that there was a risk of accidental overdosing and that there are high levels of self-neglect. He planned to discuss with Joe a proposal for a Depot injection and a Community Treatment Order (CTO)[12] as it was felt that this would give him the best chance of not relapsing again. The meeting did try to engage Joe in discussion but he left the meeting and slammed the door. There were no further notes about the plan for a CTO on discharge.

It was recorded by Devon Partnership Trust that the ward had previously submitted a Duty to Refer (DTR 4.) but that Exeter City Council Housing Dept had declined this. Housing were not invited to this meeting, and the next day Housing did indeed close this down (DTR 4), with their records stating that “as Joe was in hospital and there was no known discharge date, he was not without housing at that time”. This decision was significant as there was no further contact between the ward and the housing department until the day of Joe’s discharge, 6 weeks later. The supported accommodation project officer met with Joe on the ward and had a discussion around finances after which they contacted both his Care Coordinator and his DCC Social Worker to advise that Joe had engaged in a discussion about what Joe felt his support needs were. Joe had said that he wanted to give up drugs and continue taking his medication. Joe did not know what his support needs were other than to have housing and to remain drug free. Joe had also said that he would like a referral to Workways as he had become used to not working and he wanted to consider training opportunities.

In a ward round the next week Joe agreed to take depot antipsychotic medication, he was thought to be capacitated and agreed to engage with DCC to avoid being homeless on discharge. These were significant conversations with Joe, in that he had engaged with professionals at this point and there were opportunities to set up aftercare with him.

Reflection Point 6. It appeared that during ward rounds towards the end of his admission, Joe was more receptive to engage with assessments of his needs for support for his mental health, substance use and housing needs, however despite this no aftercare was put in place prior to his discharge.

October 2023 – An Occupational Therapy assistant noted Joe’s engagement with ward-based assessment. The next day at a ward round, Joe attended and said that he was feeling good. Consideration was given to a Russell Clinic Referral. (Russell Clinic is a DPT Inpatient Rehabilitation Ward). At a ward round the next week, it was explained that the Care Act Assessment was being completed, however this had not been completed by the DCC Social Worker. A needs assessment summary was completed by the discharge coordinator for the ward. Joe was still homeless and the recommendation from this was that Joe required a low level supported accommodation as it was considered that 24 hour support may cause Joe to struggle. The recommendation would be for 14 hours one to one support, with a review after 6 weeks.

Later this day Joe again went missing off the ward and was reported to the police as missing. Upon return Joe tested positive for cocaine and cannabis. Four days later a suitability Assessment for Russell Clinic found that Joe was not suitable, as it is an Open Rehab ward and Joe would need to abstain from using illicit drugs. At the next ward round the concerns regarding Joe’s vulnerability on the street were discussed. Joe had been offered support with his drug use and had agreed to a referral to Together Drug and Alcohol services. He was not allowed further unescorted leave, due to the risks of going missing and further drug use. It was also discussed that his planned discharge was on the coming Monday. His Social Worker made a referral to Westward Housing as they had some vacancies, while it was also identified that it will be a challenge to get Joe to see the assessors if he is street homeless. There was no response to this referral and no further attempts to see Joe by the Social Worker prior to his discharge.

KPE 4. 26th October 2023-31st October 2023

Joe discharged to the community and unsuccessful attempts to complete a housing application.

Joe was discharged on 26^th October with no fixed address (NFA). His discharge summary noted that he was started on Zuclopenthixol depot under shared care. Concerns escalated from community partners the next day (day centres, supported accommodation project), with emails highlighting the risks arising from a lack of coordinated discharge planning and related risk of exploitation.

A Duty to Refer (DTR. 5.) was submitted later the day of his discharge, by his former worker at the supported accommodation project. She expressed concern about the cold weather and lack of basic supplies (e.g. tent, sleeping bag-which were then arranged as a last resort). Joe was temporarily housed at a B&B Hotel for a week, funded by his mother (unknown to him). He was also provided with a mobile phone via supported accommodation project and day centre staff, who had arranged a taxi to collect him from the ward and bring him to the day centre. There was a plan for him to be taken from there to meet his Care Coordinator at the HCMHT. He was contacted by the Housing Case Worker via his new mobile phone, with a view to complete an urgent assessment, but Joe seemed unable to understand this. The housing worker then planned to meet Joe at the office of the HCMHT the next day to attempt this assessment.

Joe missed this urgent housing assessment appointment, with subsequent liaison between his Housing Case Worker and his HCMHT Care Coordinator. The next day Joe did attend the day centre early for breakfast and was let in, despite this being before the centre was usually open to the public. Later that day Joe went to the HCMHT office to meet his Care Coordinator.

There was then another attempt to complete his housing application, initially over the phone, but this was not feasible. However, another Housing Case Worker arrived at the office and took over the assessment in person. Joe appeared intoxicated and requested that his Care Coordinator answer the questions on his behalf, before Joe stated he could not cope and left. A further face-to-face appointment was arranged then for 31st October. However, tragically Joe was found deceased earlier on that day, his body having been discovered in a carpark.

[1] The Pathfinder Scheme is a Deferred Caution and Deferred Charge scheme run by Devon and Cornwall Police, aimed at reducing harm and reoffending through community-focused interventions.

[2] https://www.nhs.uk/medicines/olanzapine/

[3] https://exeter.gov.uk/media/nsmfpqiz/exeter-duty-to-refer-protocol.pdf

[4] https://www.gov.uk/pip

[5] a GP practice located in the centre of Exeter. The surgery is dedicated to providing accessible healthcare to vulnerable members of the community, including those who are homeless or vulnerably housed.

[6] The Approved Mental Health Professional Service manages the process known as a Mental Health Act assessment through which a person’s mental health is assessed, following a request to do so by other professionals or a person’s Nearest Relative. This is to reach a decision about whether they need to be admitted to a mental health hospital (often referred to as a psychiatric hospital), including as a detained patient under the Mental Health Act (MHA), or whether they need other forms of support.

https://www.proceduresonline.com/swindon/adults/chapters/default_chapters/p_amhp.html

[7]https://www.google.com/url?sa=t&source=web&rct=j&opi=89978449&url=https://www.dpt.nhs.uk/download/RGeHdDH99J&ved=2ahUKEwj6n4WKytCOAxVmQkEAHZA2I1cQFnoECBgQAQ&usg=AOvVaw1w0ElkCQXILIj-FsdZtW93

This agreement covers decision making as to when DPT might lead on S42 Enquiry. The Care Act requires that each Local Authority must make enquiries or ensure others do so if it believes an adult is, or at risk of abuse or neglect. It is important that the most appropriate agency leads the enquiry to ensure that people are provided with the most appropriate support to meet their individual needs and are enabled to achieve positive outcomes. The specific circumstances will often determine who the right person is to begin an enquiry. In many cases a professional who already knows the adult will be the best person. The local authority retains the responsibility for ensuring that the enquiry is referred to the right place and is acted upon. DPT will lead on enquiries in circumstances as detailed in the s75 Partnership Agreement between DCC & DPT.

[8] A hostel license is personal permission to occupy a room, not a full tenancy, meaning you get basic accommodation and sometimes services (like cleaning) but usually lack exclusive possession and strong legal rights (like long notice periods).

[9] https://www.legislation.gov.uk/ukpga/1983/20/section/3

[10] https://www.legislation.gov.uk/ukpga/1983/20/section/17/enacted

[11] https://www.researchinpractice.org.uk/media/aazjv3nz/adults_section-117_pg_web.pdf

[12] https://www.mind.org.uk/information-support/legal-rights/community-treatment-orders-ctos/overview/

3. Appraisal and analysis of practice against Terms of Reference

This section contains a discussion and appraisal of the practice found in this case, set out against the agreed Terms of Reference for the SAR.

3.1 Did the involvement of partner organisations with Joe indicate what currently either supports or hinders effective practice, as set out in the ADASS Briefing on Adult Safeguarding and Homelessness

3.1.1 Person centred practice and recording issues

Joe clearly experienced significant mental and physical ill health, as well as substance misuse/dependency. Although there was little known of his early life and any experiences of trauma were not identified, agencies who worked with Joe were concerned about his vulnerability and he would clearly meet the definition of MEH, while also at risk to harm from both abuse and self-neglect.

There was learning identified regarding the location of clinical records by the Devon Partnership Trust Care Coordinator from the HCMHT. From the time of his allocation (Jan 2023) until the time of Joe’s admission (August 2023) all records were kept in the calendar section of DPT recording system, rather than in case notes (as would be the expected practice). The location of contacts made showed some evidence of person-centred work to keep in contact by his Care Coordinator. It was difficult to evaluate the quality of person-centred work completed by statutory services in the community, due to a lack of available evidence from Joe’s case notes.

The involvement of the DCC Social Worker was not found to have been well recorded on the DPT recording system (Systm1), with a lack of details being retained on the system to accurately reflect the attempts to engage with and assess Joe, both prior to and during his hospital admission. It was not clear how well Systm 1 was used or whether this was a practitioner issue rather than an IT issue. There was learning about improving the quality of person-centred practice and recording by both DPT and DCC staff.

3.1.2 Professional curiosity

“Professional curiosity is especially important when there are episodes of non-engagement. Is the person unwilling and/or unable to engage? Has sufficient account been taken of the impact of stigma and shame, or of how services are organised? Not everyone can manage office- based appointments at set times. Outreach may be more effective. Are services being sufficiently creative and flexible, making reasonable adjustments in line with the Equality Act 2010? Are the right questions being asked? It is too easy to close cases without stepping back to ask if everything has been done to stay alongside the person”[1].

The above quote is included given that statutory services were not effective in engaging with Joe. For example, both the Care Coordinator (from DPT HCMHT) and the Social Worker from (DCC Mental Health Social Work Team) did make attempts to meet and assess him, which were sometimes avoided by Joe. After an introductory visit by the Social Worker in May 2023, there were no more notes until the Social Worker attended a meeting in July 2023, with the supported accommodation project worker requesting another visit as Joe had agreed to work with the Social Worker. A visit was then attempted but Joe had gone out. The next visit was while Joe was in hospital, but he refused to engage and following this the Social Worker said he would close his case. The supported accommodation project worker again requested the Social Worker visit in September after he had met Joe, who said he was willing to engage with the assessment. However, no further visit was made by the Social Worker prior to Joe being discharged in October.

The assessment of Joe’s needs was made more challenging by both his poor mental health and difficulties with engagement. However, Joe stated to his supported accommodation project worker that he was willing to be assessed at least on 2 occasions, both in the supported accommodation project and while in hospital. Clearly, opportunities to involve his worker from supported accommodation project to facilitate the duty to assess Joe were missed on several occasions. Even though Joe struggled to participate, there was knowledge of Joe’s care and support needs from other staff who had known Joe for years, including his Care Coordinator from the HCMHT, day centres (where concern about his poor living skills, including cooking had been known for years), supported accommodation project (where repeated concerns about his needs led to multiple referrals). Joe had been in hospital for 3 months and knowledge about his current functional ability was potentially available for use by the Social Worker in completion of an assessment, even though he would not agree to meet with the Social Worker when he did try to visit him.

There was a duty to assess his care and support needs, as set out under Section 9 of the Care Act (2014). However, as Joe did not agree to meet with the DCC Social Worker this duty was not met by him, although the hospital discharge coordinator did manage to complete a summary of his needs, identifying 14 hours of support as part of accommodation needs may have been suitable. This identified level of need was not met prior to Joe’s discharge from hospital, resulting in significant risks.

In terms of risk assessments, a key issue was the risk of drug overdose upon discharge, given Joe’s significant substance misuse history. While this was recognised in ward rounds, it did not inform a suitable plan for this to be managed. As Joe’s tolerance to opiates was reduced by his reduced usage during the admission, a return to his previous level of opioid intake could put his health at a significantly increased risk. It was not clear that this was considered, nor discussed with Joe before he was discharged. Although he was referred to Together[2] for substance misuse support, this did not result in any specialist dual diagnosis assessment, advice or services being offered to him before his discharge.

Practice Point 1. Discharge planning took place too close to the discharge date for any activity to successfully meet assessed needs for accommodation and support, resulting in high risks of drug overdose which were not addressed.

Practice Point 2. Joe had dual diagnosis and his presentation was clearly complex, however there do not appear to be specialist dual diagnosis services currently in Devon.

When exploring the duties to assess Joe it is also relevant to consider whether his refusal to engage with the assessment should be taken as grounds to close his case and thereby negated the duty to assess him. Under Section 11(2b) of The Care Act (2014) it requires a local authority to complete an assessment even if an adult refuses to engage in this process, where either the adult lacks mental capacity to refuse and an assessment is in their best interests, or the adult is experiencing/or is at risk of abuse or neglect, including self-neglect[3]. On this basis, there were statutory duties for the local authority which did not appear to have been met, as there were safeguarding concerns relevant to this duty for Joe.

Practice Point 3. This raises a consideration for DCC about ensuring that referrals for Care Act assessments are not closed due to non-engagement when there is an outstanding duty to complete the assessment.

[1] 25.158 Briefing on Adult Safeguarding and Homelessness (Page 18)

[2] https://www.waythrough.org.uk/find-support-near-me/together/

[3] https://www.legislation.gov.uk/ukpga/2014/23/section/11

3.1.3 Family history and understanding context to current presentation

“Involvement of family and friends might assist with understanding and resolving issues of engagement. Are there circles of support to tap into? Where family and/or friends are not available, the principle of empowerment should lead to consideration of advocacy to enable people to participate in assessments and planning”[1].

From the information available to the SAR there was no detailed summary of Joe’s history, in terms of his personal life experiences and any associated trauma he may have experienced, which could have contributed to his Multiple Exclusion Homelessness. This seems to be a significant gap in positive practice with him. It does appear to have been a significant omission based on available information. For example, his family history, any personal relationships he had, or any other events contributing to his at times significant mental health difficulties and substance abuse. For any work on these areas, trauma informed practice is recognised as central to understanding current behaviours and engagement difficulties some adults may have.

The only reference from any service to Joe’s family was in his last days when his mother paid for him to stay in a B&B hotel for a week, without his knowledge, when he was discharged homeless from hospital. The process of engagement with his mother, who this was by and how this took place, was not available to the SAR. But given that she did agree to pay for this, it would seem reasonable to have attempted to work with her as part of good practice principles when assessing and supporting Joe, far earlier in the timeframe subject to review, which seemed a significant missed opportunity to understand the context of his current presentation.

[1] 25.158 Briefing on Adult Safeguarding and Homelessness (Page 19)

3.1.4. Thorough Mental Capacity Act (2005) and Mental Health Act (1983) assessments.

Joe’s mental health and associated mental capacity were key aspects of this case, both of which were related and highlighted repeatedly in relation to risks to himself and from others. Both these areas were further complicated and affected by his extensive and repeated use of drugs throughout the review period.

3.1.4.1. Mental Capacity Act (2005) assessments

In August and September 2022 safeguarding concerns were raised to DCC Integrated Adult Social Care by the supported accommodation project regarding Joe being financial abused. The referrer stated they believed Joe frequently lacked mental capacity to take decisions about risks. These were forwarded to DPT and the assigned Social Worker responded to DCC safeguarding team that he believed that Joe lacked mental capacity around his accommodation and finances, suggesting that an application to the Court of Protection (CoP) for Deputyship could be considered, but no further action appeared to be taken by any agency, neither about the safeguarding nor a consideration of a CoP application.

These concerns were repeatedly raised in subsequent safeguarding referrals (Jan 2023, July 2023) the second of which did progress to a Section 42 (2) Safeguarding Enquiry, however there was no records of mental capacity assessments being completed by DPT.

The DCC Social Worker (at an A2A meeting in August 2023), felt that Joe had mental capacity to refuse offers of assessment. However, there was no record of a mental capacity assessment having been completed prior to this view being made and the Housing Case Worker noted that concerns of Joe’s mental capacity remained. There was no further reference to mental capacity until notes from a Consultant at a ward round in September stated that Joe had mental capacity to consent to depot antipsychotic medication, at which stage he was happy to continue with this and to work with services.

At a further ward round it was acknowledged that Joe would need a mental capacity assessment for housing, at this stage low support accommodation was recommended for him. This was not completed and Joe was discharged from the ward, in subsequent attempts to meet and complete housing applications his mental capacity was once again raised, but he was not seen for any assessment to be completed, prior to his death. While Joe’s mental capacity would be likely to have fluctuated during the review period there was overall a lack of sufficient assessment to explain and defend views as to what decisions and at what times Joe had mental capacity to manage risks related to his care and support, or risk of abuse.

Practice Point 4. This raises an important aspect of practice, which has previously been identified through national and local SARs, that of insufficient MCA assessments. In this case while undoubtedly complex, due to the relationships between his mental health, substance misuse and mental capacity, remains an important potential area for improvement. As this has already been identified as action needed locally in previous SARs by the TDSAP, it is not repeated in this SAR.

3.1.4.2 Mental Health Act (1983) assessments

Joe did experience mental health difficulties throughout his adult life and partner agencies struggled to engage with him about these. He had psychotic hallucinations and delusions which caused him distress and disturbances in his behaviour, putting him at risk from others. For most of the SAR period he did not take medication for this and did not want to be seen by mental health services while in the community. As set out elsewhere, due to the escalating risks of harm from both self-neglect, substance misuse, financial abuse and impending homelessness he was assessed under the Section 2 of the Mental Health Act (1983) and admitted to hospital on the 28^th July 2023.

He was re-assessed and further detained under Section 3 of the Mental Health Act (1983) on the 24^th August 2023, until he was discharged from hospital on the 26^th October 2023. At a ward round prior to this discharge the use of a Community Treatment Order[1] (Section 17A. Mental Health Act (1983)) was discussed, but this was not pursued. Overall, Joe struggled to accept support for his mental health although towards the end of his admission he did appear to agree to take depot antipsychotic medication in the community. Unfortunately, due to his death shortly after discharge from hospital he did not get the opportunity to engage with community mental health services following his formal hospital admission.

[1] https://www.legislation.gov.uk/ukpga/1983/20/section/17A

‘The second domain focuses on the multi-agency, multi-disciplinary team around the person and this section focusses on analysis of how well partner agencies worked together.

3.2.1. Multi agency meetings

“One component of working effectively together is use of multi-agency meetings, whether framed as high-risk panels, complex case panels, harm reduction forum or multi- agency risk management meetings. They are a necessary response to the often-reported difficulty of getting the right people around the table to engage in problem solving. The focus is on sharing responsibility, working flexibly across service and organisational boundaries, and offering ideas and solutions. Respectful of each other’s expertise, no handoffs are allowed. Plans should be agreed, with clear lines of responsibility, contingency planning and mechanisms for reviewing outcomes. Given the risks inherent in many cases, multi-agency meetings offer a framework to reach for safer uncertainty where wellbeing outcomes cannot be guaranteed”[1].

[1] 25.158 Briefing on Adult Safeguarding and Homelessness (Page 23)

3.2.1.1. A2A Meetings

Throughout the period of the review there were several agencies involved in Joe’s care and communication between these agencies highlighted some opportunities for multi-agency working to assess his needs. The multi-agency system used to organise these were mainly the A2A (Access to Accommodation) process. He was discussed at A2A meetings regularly, with references made to Joe on 5 occasions (February, July 2022, March, August, September 2023), however these did not lead to Joe being referred for specialist supported mental health housing services and partners responsibilities to act on recommendations were unclear.

While the A2A meetings facilitated communication and collaboration between agencies, the overall success in addressing Joe’s needs was limited. Despite the efforts made during these meetings, Joe’s engagement with agencies remained poor, and his mental health and substance misuse issues persisted.

3.2.1.2 Professionals Meeting

Apart from A2A meetings, there was one further multi agency meeting found during the time frame. This was requested by supported accommodation project staff, due to their difficulties managing his mental health/substance misuse and associated vulnerabilities. This meeting was held at the supported accommodation project in July 2023 and involved professionals from DPT (HCMHT) and DCC Assigned Social Work Team, although GP surgery staff were unable to attend. Discussion focused on Joe’s ongoing psychosis, auditory hallucinations, paranoid delusions, and trauma issues. The outcome of this was a plan to assess and subsequently to detain Joe under Mental Health Act (1983), which was done, although there was no other action to address his housing needs as part of this.

Despite further requests by the supported accommodation project to have meetings to address his upcoming housing needs during his admission (in August, Sept, Oct 2023) there were no more meetings held prior to his hospital discharge. Just prior to the meeting in July supported accommodation project staff had raised a safeguarding concern in relation to the above issues, as a means of seeking multi agency input and although the meeting was retrospectively included in the safeguarding enquiry report from DPT, the meeting was not at the time held as part of a safeguarding process. This showed the importance of meetings being held as part of formal processes rather than more informal gatherings of professionals, as there was a lack of ownership of responsibility to plan for his future, beyond his hospital admission at this time.

3.2.1.3. Section 117 Aftercare Meetings

The ward where Joe was admitted held several regular reviews of his progress at ward rounds and towards the end of his admission also designated one of these meetings as Section 117 meetings (13/09/23). However, it appeared that only inpatient staff were present at this meeting and no community services were invited. At the meeting Joe attended but refused to discuss his aftercare needs and left. Below is an extract from the notes taken at the meeting:

‘Acknowledged that Joe is currently homeless and therefore any discharge would be a homeless discharge. The Responsible Clinician considered risks during the meeting. No recent history of intentional overdosing. Last overdose was 10 years ago. She recognised that there was a risk of accidental overdosing and that there are high levels of self-neglect.Planned to discuss with Joe a proposal for a Depot injection and a Community Treatment Order as it was felt that this would give him the best chance of not relapsing again. The meeting did try to engage Joe in discussion. However, when they talked about his rights for aftercare, he left the meeting and slammed the door’.

The DTR process was closed in September 2023, which was not communicated by the Exeter City Council Housing Worker to the ward for consideration at a Section 117 aftercare planning meeting. This was not a multi-agency meeting, and no suitable plan was made to address Joe’s needs for care and support in the community and the risks of a homeless discharge.There was no record of an MDT being held pre-discharge and this led to crisis work being attempted unsuccessfully to complete Housing assessments in the days immediately after his discharge. If an MDT Section 117 meeting had been held before he was discharged this could have been avoided.

“Some services or partnerships employ navigators to help service users access appropriate provision. Leaving aside, for now, the question of whether the need for navigation means that systems are too complicated, or that services don’t exist and/or are gatekeeping to manage limited resources, what is clear is that service users and practitioners need to understand pathways into provision. For example, what locally is the pathway with respect to co-occurring mental ill-health and substance misuse or patients who are homeless and working collaboratively to avoid discharge to no fixed abode?”[1]

Substance misuse was a major factor, affecting Joe prior, during and following his admission to hospital but there were no assessments detailing the nature and degree of his substance misuse. References were made to crack cocaine, heroin, spice, cannabis and ecstasy use at various times. The week prior to his discharge from hospital a referral to Together Drug and Alcohol services was agreed with Joe, but there was no record to show that this was completed and no clarity regarding any dual diagnosis pathway or services were found.

Practice Point 5. Collaboration between mental health services, physical health services, and substance misuse services was essential in providing comprehensive support to Joe, but there was no evidence of this found during the review. This was a significant missed opportunity given the complexity of Joe’s needs.

[1] 25.158 Briefing on Adult Safeguarding and Homelessness (Page 23)

3.2.1.4. Adult safeguarding enquiries and meetings

The other relevant area of potential multi agency work which would have given additional opportunities for shared decision making was that of safeguarding adults, a multi-agency process with established duties, set out under both Section 42 The Care Act (2014) and in TDSAP Multi-agency safeguarding adult procedures and guidance’s 2021[1]. Also, of relevance to this process is the Safeguarding Adults Agreement between DCC and DPT[2]. This sets out the circumstances and processes for when safeguarding adult enquiries will be led by DPT, including where the adult is open and allocated to DPT staff, as was the case with Joe.

Of the five safeguarding concerns raised by supported accommodation project staff to DCC, for consideration of Section 42 duties to undertake enquiries, only the final concern was progressed to Section 42 (2) and “caused out to DPT” to lead on undertaking this enquiry, the outcome and oversight of this enquiry was not recorded until after Joe died.

The risks outlined in these five concerns were;

three for financial abuse (other resident of supported accommodation project/other homeless community members having his bank card and taking his money),
two of Joe neglecting his home environment and lacking mental capacity about the risks to his tenancy,
one of threats from others arising due to his disturbed behaviour in supported accommodation project.

Devon County Council Integrated Adult Social Care has recognised the practice in this case did not meet expected standards on the part of the DCC response, with no evidence of a sufficient response to gather information, involve Joe, or other agencies, nor to ensure risks were assessed and managed.

There were a series of significant missed opportunities for multi-agency work to address the above ongoing risks, which could have been addressed through safeguarding adult procedures and holding meetings as part of safeguarding enquiries to plan for his protection.

Each of the various systems explored during this review which were used to facilitate multi agency work in this case were ineffective on their own in bringing together all the necessary partner agencies.

Practice Point 6. A more joined up approach to multi agency work in this case would have facilitated gathering of the necessary information to complete an assessment of his needs and risks which could have been used to provide the required support prior to his discharge and could have avoided him being discharged homeless from hospital. An agreed lead agency with a named worker would have assisted this aspect of the case and the lack of this hindered multi-agency work.

[1] https://www.devonsafeguardingadultspartnership.org.uk/document/multi-agency-safeguarding-adults-guidance-and-procedures/#stage-one-concerns

[2] C19_Appx2_Annex4_Safeguarding_Adults_Nov21

3.3. For people at risk of Multiple Exclusion Homelessness, what learning can be identified from Joe’s circumstances for partner organisations, regarding provision and accessibility of sufficient and suitable accommodation, in line with relevant Housing duties and responsibilities

Duties and associated responsibilities to meet Joe’s housing need were referenced on multiple occasions through agency contacts with him, under three different duties and these are discussed in the sections below (Housing, Mental Health and Adult Social Care law).

3.3.1. Housing Act (1996) duties

“Part 7 of the Housing Act 1996 (as amended by the Homelessness Reduction Act 2017) enables a person to apply to a local housing authority for housing assistance. If the authority has reason to believe that the applicant may be homeless or threatened with homelessness, it must make enquiries to determine whether they are eligible for assistance and, if so, whether any duty is owed to them (section 184).

Since October 2018 certain public authorities must refer people who are or may be homeless, or threatened with homelessness, to a local housing authority (section 213B). This duty requires the person’s consent, and choice of which local housing authority receives the referral, and applies to prisons, probation services, hospitals providing in-patient treatment, urgent treatment centres and social service authorities[1]”.

Effective prevention of homelessness requires pre-release/discharge planning and when considering the Duty to Refer (DTR) referrals for Joe, this aspect of work fell below expected standards, as set out in the Exeter Duty to Refer Protocol Feb 2021.

‘You can refer a service user to us as soon as their housing situation becomes less secure, for example if: They are approaching discharge from hospital, armed forces or release from custody, with no accommodation available to them. Submitting the form will trigger the following: If there is reason to believe that the person is eligible, not homeless but threatened with homelessness in 56 days, a homelessness application will be taken, and a prevention duty will be accepted’[2].

There were several DTRs raised by supported accommodation project staff to prompt statutory housing services to move Joe onto more suitable housing prior, during and after his hospital admission. These did not result in any offer of alternative, or more appropriate accommodation for Joe.

After admission DTR (4) was raised by discharge coordinator on the ward (as DTR (3) had not been received by ECC), this was accepted and assigned to a Homelessness case worker, who explored why he couldn’t return to supported accommodation project and that Joe refused to have an assessment by a Social Worker. As Housing could not offer any higher supported accommodation than the supported accommodation project and there was no indication of a discharge date, the DTR (4) was closed on 14^th September 2023. It did not appear that the referrer (discharge coordinator) was informed of this decision at the time although this had been discussed at the Section 117 meeting. There was no further contact between the ward and the housing dept for 6 weeks until after Joe’s discharge.

In October 2023 DTR (5) was raised by the supported accommodation project (despite no current role with Joe) on the day he was discharged from hospital. This was again accepted and despite attempts to complete a homeless application on this and subsequent days, Joe was unable to participate in this prior to his death 5 days later. The DTR process did not lead to a prevention of homelessness.

It did appear that accommodation via housing legislation would have been unsuitable for Joe, but no action was taken, possibly with the hope that a Social Worker’s Care Act (2014) assessment of his needs for care and support might lead to the offer of alternative, higher support accommodation. However, as set out earlier in the report this assessment was not completed by the DCC Social Worker and although the discharge coordinator did complete an assessment no alternative accommodation was found, leading to crisis planning (involving a tent, sleeping bag) and his mum funding a B&B as an alternative to rough sleeping on the street.

Practice Point 7. The learning from this review demonstrates that there was an absence of multi-agency discharge planning and despite several DTRs triggering housing duties, they were unable to prevent him becoming homeless.

[1] The Homelessness (Review Procedure etc.) Regulations 2018.

[2] https://exeter.gov.uk/media/nsmfpqiz/exeter-duty-to-refer-protocol.pdf

3.3.2. Mental Health Act (1983), Section 117 Aftercare duties

Under Mental Health law, specifically Section 117 of the Mental Health Act (1983), there is a duty to offer and provide aftercare services for adults detained under Section 3 of the Mental Health Act (1983). This can include either specialist supported accommodation, or residential care, if this is part of their overall assessed aftercare needs. The planning for this should begin as soon as the person is admitted and not waiting until their date of discharge. Clearly in Joe’s case this was not done and appeared to be in breach of this duty.

‘Aftercare services and accommodation. While s117 aftercare is unlikely to cover a person’s basic housing needs, accommodation, such as residential care and supported accommodation, can be provided under s117 if this falls within the purpose of aftercare services under s117(6) (i.e. to meet the person’s mental health needs and to reduce risk of a deterioration of the person’s mental health condition and hospital readmission). The MHA Code (33.10) states: Although the duty to provide aftercare begins when the patient leaves hospital, the planning of aftercare needs to start as soon as the patient is admitted to hospital. ICBs and local authorities should take reasonable steps, in consultation with the care programme approach care coordinator and other members of the multi-disciplinary team, to identify appropriate aftercare services for patients in good time for their eventual discharge from hospital or prison’[1].

Practice Point 8. As Joe’s needs for mental health aftercare would have included the need for suitable supported housing (sometimes known has “housing plus”, on the basis that the DPT discharge coordinator identified he needed a form of supported accommodation), this should have been identified as part of Section 117 responsibilities well before his discharge from hospital, which was not done and led to his homeless discharge.

[1]https://www.researchinpractice.org.uk/media/aazjv3nz/adults_section117_pg_web.pdf

3.3.3. The Care Act (2014)

Local authorities have duties under the Care Act (2014) to meet eligible needs for care and support (Section 18, Care Act (2014)). This may include providing accommodation when it is necessary to meet those assessed needs. This duty arises when a person’s needs, stemming from a physical or mental impairment or illness, affect their ability to achieve certain outcomes, such as maintaining a habitable home environment. If a person’s needs are deemed eligible under the Care Act and cannot be met without accommodation, the local authority must ensure suitable housing is provided. Accommodation can, therefore, in some circumstances, fall within Care Act duties where it is necessary to meet eligible care and support needs.

However, the SAR recognises that The Care Act (2014) does not create a general duty to resolve homelessness and accommodation should only be provided under the Care Act where it is necessary and proportionate to meet assessed eligible needs, and where those needs cannot be met in other ways. In this case it would be the responsibility of Devon County Council Integrated Adult Social Care to meet Joe’s eligible needs, including through accommodation, if this was thought necessary following a Section 9 assessment.

However, this should not be taken to support a broader use of the Care Act (2014) to compensate for limitations within housing pathways. As this could inadvertently lead to over-extension of adult social care responsibilities, including escalation to higher-cost or more restrictive provision such as residential care.

Nonetheless there were duties under both the Care Act (2014) and the Mental Health Act (1983) to Joe, in both cases these would be the responsibility of Devon County Council, the Section 117 duties for assessing and arranging aftercare were for the Social Worker from DCC, (as set out in the Section 117: After-Care under the Mental Health Act 1983 Devon Wide Joint Protocol[1]).

In summary, the learning from this case illustrates the potential for confusion arising from multiple potential legal frameworks for the provision of accommodation. The appropriate legal framework depended on the nature and level of the needs for care and support identified.

Clearly efforts were made to assess Joe’s needs, including those for suitable accommodation during his admission to hospital, which were unsuccessful, partly as he struggled to engage consistently with the assessing DCC social worker. It is acknowledged that this raises practical, ethical and legal complexities for practitioners, whereby workers need to balance persistence with proportionality capacity and autonomy.

Despite this, a needs assessment summary was completed by the DPT discharge coordinator and his entitlement to aftercare for his mental health, did include a recognition for suitable accommodation to be explored as part of his aftercare, however, it was not specified whether this was a duty under S9 The Care Act 2014 or as part of S117 Mental Health Act 1983.

It was unclear which duty was deemed the appropriate one for Joe, leading to lack of clarity about professional and organisational duties. It would appear that this was further complicated by a lack of available higher support housing options, for example supported living plus additional outreach or top up/floating support, which might have be a more suitable, proportionate and less restrictive option for Joe than the traditional residential care type model of service.

Practice Point 9. The lack of any supported housing provision whether under the Mental Health Act (1983) Section 117, or The Care Act (2014) would be the responsibility of DCC, prior to his homeless discharge. Neither duty were met and this was the most significant missed opportunity to work with DPT to alter the outcome in this case. Clearly the legal framework potentially adds complexity and may cause confusion about which agency holds the lead responsibility for accommodation in MEH cases, but due to the above analysis this review identified that where accommodation is a need, as part of meeting care and support needs, this was DCC Adult Social Care.

Practice Point 10. The review identified that there was also a lack of suitable accommodation available to meet Joe’s needs, when this was sought in the days immediately prior to his discharge. Devon does not appear to have a sufficient range of housing services to offer to individuals who present like Joe.

[1] https://www.dpt.nhs.uk/download/s117-aftercare-m01.docx?ver=2602

4. Findings and recommendations from the review

This section contains the priority findings from this SAR, from analysis of the work undertaken with Joe. Recommended areas in response to each Finding for service improvement are set out for the TDSAP in this section of the report.

Finding 1.

Where an adult who experiences Multiple Exclusion Homelessness and is found to be hard to engage by statutory services, the current arrangements for addressing this are not effective. This may lead to duties around both Care Act assessments and safeguarding enquiries not being met, while there is also currently a lack of sufficient guidance to support multi agency work to help coordinate and creatively overcome barriers, if the adult does not engage, to ensure that assessments of needs and risks are suitably completed.

In this case, under the local Section 75 partnership agreement between Devon County Council (DCC) and Devon Partnership Trust (DPT), Care Act (2014) assessment and Section 117 social care assessment duties, for people experiencing mental health difficulties, are delivered by DCC assigned social work staff working within Devon Partnership Trust integrated teams. While DCC retains the statutory responsibility for Care Act assessments and safeguarding enquiries, it may cause out the lead role for safeguarding to other agencies. For individuals eligible for Section 117 Mental Health Act (1983) aftercare, responsibility for providing and coordinating ongoing aftercare support is shared between health (DPT) and social care (DCC), with DPT typically leading safeguarding enquiries caused out to them and assigning these to a DPT care coordinator.

The review found that the interface between the Care Act assessment and safeguarding processes and Section 117 aftercare responsibilities was not effectively managed with limited coordination or joint working between DCC and DPT. As a result, neither statutory duty was fully met. The organisational structure can hinder the completion of overlapping duties and contributed to uncertainty about professional responsibilities. This led to confusion, gaps in support and missed opportunities for coordinated aftercare.

This is a national issue which has recently been highlighted in the Govt National Plan to end Homelessness[1]. “In addition to interventions to prevent discharge from hospital into homelessness, we will also take action to strengthen the way that housing, social care and safeguarding services work together to prevent homelessness, particularly for people with complex needs. To support this, we will: Review and update the relevant areas of the Care Act 2014 statutory guidance, particularly in relation to councils’ safeguarding responsibilities and how they should act on these to support people at risk of homelessness and rough sleeping. Publish new support guidance, alongside consulting on the statutory guidance, to help staff working across these services to respond to common challenges. This will clarify relevant statutory responsibilities under the Care Act 2014, promote legal literacy, and offer practical reflections to support more confident, coordinated safeguarding practice’.

Recommendation 1.

System wide learning and recognition of MEH issues, self-assessment of practice and improved understanding of needs in the MEH client group.

TDSAP to seek assurance from identified partners working with rough sleepers of the adoption of both the MEH terminology and use of the MEH Safeguarding Toolkit[2].

a. Introduce and embed terminology that more accurately captures the distinct needs of people experiencing Multiple Exclusion Homelessness (MEH);

b. Evaluate current safeguarding practice for this group using the MEH toolkit as a structured self‑assessment tool; and

c. Develop a multi-agency plan over the next 6 months to get a clearer local picture of need, by focusing on assessments to identify adults with Care Act eligible needs amongst MEH population.

It is acknowledged that work has already begun in relation to improvements regarding awareness of the MEH community in Devon, which forms part of the wider current service improvement plan for DCC Integrated Adult Social Care. Multiple Exclusion Homelessness workshops have been facilitated and a leadership session had a particular focus on MEH and the impact on individuals (this was multi-agency and facilitated). Integrated ASC has already agreed to roll out the MEH toolkit developed by Kings College London, as referenced above.

Context: As of 1^st April 2026, the County Council will no longer be the commissioner of Homelessness 18+ provision in Devon. The lead role for commissioning will move to the district councils and Devon County Council will become a contributor of funding in recognition of the significant health inequalities often experienced by homeless individuals. Commissioning functions for drug and alcohol treatment services and domestic abuse sit with Public Health and Communities within Devon County Council.

Recommendation 2.

Audit activity to be undertaken to provide assurance on the timeliness and quality of practice in fulfilling Care Act and S117 aftercare duties where a person is not engaging, specifically in relation to the following areas, including communication back to referring agencies on the outcomes of referrals:

DCC

a. Section 42 (1) decision‑making, and outcome communication back to referring agencies.

b. Section 9 assessments of care and support needs for people with mental health difficulties undertaken by the DCC social work assigned staff. This should include consideration of whether sufficient personal and social history is gathered to inform a trauma informed approach to support context of current needs for care and support.

(This has been agreed as part of the Integrated Adult Social Care service improvement plan, with a focus to the audit in particular on Section 11 duties, whereby the duty to undertake Section 9 assessments remains even if an adult withholds consent, where the adult is also experiencing, or at risk of, abuse or neglect).

Joint DCC and DPT

c. Section 42 (2) safeguarding enquiries for people with mental health difficulties caused out to DPT by DCC.

d. Section 117 aftercare planning and support

Safeguarding Adults Reviews (SARs) undertaken in relation to ‘rough sleeper deaths’ recognised opportunities to improve multi- agency practice required a shift in culture to protect against professional preconceptions often applied to people with MEH backgrounds or, conversely the normalisation of a high level of risk. Both were found to negatively impacts on safeguarding decision making and related assessment process’[3].

Finding 2.

Working with adults experiencing MEH is complex and can incorporate elements of several multi-agency processes in Devon (the A2A process, the safeguarding enquiry process, MHA Section 117 Aftercare planning and the Duty to Refer for housing), despite this multi-agency meetings were not often held, even after they were requested.

This added to confusion about roles and responsibilities for decision making and leadership for subsequent actions to address concerns about the risks relating to housing, mental health and substance misuse, especially at the point of discharge from hospital. This is further complicated when individuals do not engage with offers of assessment and support by statutory services.

Recommendation 3.

TDSAP to receive assurance from DPT and DCC that multi agency meetings in the community for people experiencing Multiple Exclusion Homelessness are held as part of the above good practice MEH guidance. Also, that plans are made to identify and meet relevant legal duties by the appropriate partner, following suitable and proportionate Care Act assessments. This could be completed either as part of the current procedures for adults who are hard to engage (MARM, or as part of a Team around the Person) but should be incorporated into a commitment for the MEH good practice strategy locally as a response to this SAR.

Recent research in relation to Safeguarding Adults Reviews where homelessness was a factor recognised that agencies may have missed opportunities to protect adults at risk. Themes included a lack of leadership and coordination between agencies, challenges in performing and interpreting assessments, a lack of suitable accommodation provision, poor hospital discharge arrangements, and missed opportunities sometimes through a lack of professional curiosity or normalisation of risk.

Recommendation 4.

TDSAP to seek assurance from DPT that barriers to effective implementation of Section 117 aftercare have been sufficiently explored and an action plan implemented to overcome such barriers, including establishing whether multi agency Section 117 meetings are held and where there are gaps in resources available to meet an adults needs, including housing needs, as a key part of a Section 117 plan, these are addressed by the appropriate agency before a decision is taken that they are safe to be discharged from hospital.

The difficulties experienced by homeless people with mental health and substance misuses problems are recognised as a national challenge for service providers and has been the focus of recent government policies and practice guidance.

“Alongside ill health, some people may also have other needs, such as substance dependence, which make them vulnerable to both repeat homelessness and appalling outcomes, including death. It is therefore vital that we not only provide the right specialist services to address these needs, but also that these services support people with co-occurring needs’.

‘Implement the Co-occurring Mental Health and Substance Use Delivery Framework, developed by the Department for Health and Social Care and NHS England, which aims to improve treatment for people dealing with substance misuse and mental ill health at the same time. This framework sets out national commitments and guidance for the health sector on improving the delivery of joined-up, person-centred care across drug and alcohol treatment, and mental health services[4]”.

Recommendation 5.

Where adults are known to have both a significant substance misuse and a mental health problem, that TDSAP receive sufficient assurance from DPT and DCC that there are systems in place to ensure integrated care planning is in line with the key recommendations from the DHSC guidance for Co-occurring Mental Health and Substance Use delivery Framework[5].

Local Context.

Waythrough[6] and DPT are already progressing a joint protocol for people with co‑occurring needs, which aligns closely with this recommendation. This SAR (and the above recent national guidance) makes clear the need for system‑level assurance around dual‑diagnosis pathways, which TDSAP may find helpful from action on this joint protocol.

This should include where necessary a commitment for suitable support and health education/harm minimisation being offered as part of Section 117 aftercare planning prior to adults being discharged from mental health inpatient services, to aim for a reduction in the risks of opiate toxicity when adults may return to previous levels of drug use after a period of inpatient abstinence.

Finding 3.

There appear to be a significant increase in unmet need for housing provision, with varied levels of support for people experiencing Multiple Exclusion Homelessness in Exeter, however there is currently a lack of clarity about whether there are sufficient and suitable resources available to meet this need. This includes a lack of guidance of what support the services may receive to safely accommodate people who may be hard to engage to meet their identified needs.

Recommendation 6

TDSAP to receive assurance from statutory partners (ECC Housing Dept, DCC) that a joint assessment of the current trends around housing needs, with different levels of support needs for the MEH community be undertaken to support the identification of available services and whether there are any gaps in these.

Recommendation 7

Following this that a housing and support services resource directory, including guidance on what levels of support differing services can meet should be developed. This should be readily available for practitioners to use following MEH assessments and can be used to inform and identify future commissioning needs if there are gaps found in current availability of housing and support services.

This would help bring together commissioning responsibilities by ECC, DCC (will become district and city councils), DPT and ICB, to assist in meeting their respective duties especially for people with dual diagnosis, including to identify and plan together to meet any identified gaps in resources, whether or not people are ready to engage in work around their addictions, in order to try and address the high mortality rates and low life expectancy amongst this group as a key shared priority arising from this SAR.

As of 1^st April 2026, the County Council will no longer be the commissioner of Homelessness 18+ provision in Devon. This is because the statutory duty for housing and homelessness lies with the district and city councils. Therefore, the lead role for commissioning moves to the district councils and Devon County will become a contributor. It would be the expectation that the district council lead would bring together a local services directory which may involve contributions from the county e.g. in relation to drug and alcohol treatment, and domestic abuse provision.

[1] https://www.gov.uk/government/publications/a-national-plan-to-end-homelessness

[2] https://www.kcl.ac.uk/hscwru/assets/news/2023/nov/safeguarding-multiple-exclusion-homelessness-toolkit-2023.pdf

[3] https://www.kcl.ac.uk/hscwru/assets/news/2023/nov/safeguarding-multiple-exclusion-homelessness-toolkit-2023.pdf

[4] https://www.gov.uk/government/publications/a-national-plan-to-end-homelessness

[5] https://www.gov.uk/government/publications/co-occurring-mental-health-and-substance-use-delivery-framework

[6] Waythrough are the company who commission Together Drug & Alcohol Service in Devon

Document resources

1. Introduction

1.1 Why was this case chosen to be reviewed?

1.2 Summary of the circumstances

1.3 Timeframe, Terms of Reference, methodology and scope

1.4 Agencies represented on the SAR Panel

1.5 Reviewing expertise and independence

1.6 Involvement of family members

2. Narrative summary of key events in Joe’s circumstances

2.1 History and summary of events prior to the period subject to review

3. Appraisal and analysis of practice against Terms of Reference

3.1 Did the involvement of partner organisations with Joe indicate what currently either supports or hinders effective practice, as set out in the ADASS Briefing on Adult Safeguarding and Homelessness

3.1.1 Person centred practice and recording issues

3.1.2 Professional curiosity

3.1.3 Family history and understanding context to current presentation

3.1.4. Thorough Mental Capacity Act (2005) and Mental Health Act (1983) assessments.

3.1.4.1. Mental Capacity Act (2005) assessments

3.1.4.2 Mental Health Act (1983) assessments

3.2.1. Multi agency meetings

3.2.1.1. A2A Meetings

3.2.1.2 Professionals Meeting

3.2.1.3. Section 117 Aftercare Meetings

3.2.1.4. Adult safeguarding enquiries and meetings

3.3. For people at risk of Multiple Exclusion Homelessness, what learning can be identified from Joe’s circumstances for partner organisations, regarding provision and accessibility of sufficient and suitable accommodation, in line with relevant Housing duties and responsibilities

3.3.1. Housing Act (1996) duties

3.3.2. Mental Health Act (1983), Section 117 Aftercare duties

3.3.3. The Care Act (2014)

4. Findings and recommendations from the review

Recommendation 1.

Recommendation 2.

Recommendation 3.

Recommendation 4.

Recommendation 5.

Recommendation 6

Recommendation 7

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1. Introduction

1.1 Why was this case chosen to be reviewed?

1.2 Summary of the circumstances

1.3 Timeframe, Terms of Reference, methodology and scope

1.4 Agencies represented on the SAR Panel

1.5 Reviewing expertise and independence

1.6 Involvement of family members

2. Narrative summary of key events in Joe’s circumstances

2.1 History and summary of events prior to the period subject to review

3. Appraisal and analysis of practice against Terms of Reference

3.1 Did the involvement of partner organisations with Joe indicate what currently either supports or hinders effective practice, as set out in the ADASS Briefing on Adult Safeguarding and Homelessness

3.1.1 Person centred practice and recording issues

3.1.2 Professional curiosity

3.1.3 Family history and understanding context to current presentation

3.1.4. Thorough Mental Capacity Act (2005) and Mental Health Act (1983) assessments.

3.1.4.1. Mental Capacity Act (2005) assessments

3.1.4.2 Mental Health Act (1983) assessments

3.2. Multi agency working around Joe, focusing on how well services worked together to address his needs related to his mental health, physical health and substance misuse during the period subject to review?

3.2.1. Multi agency meetings

3.2.1.1. A2A Meetings

3.2.1.2 Professionals Meeting

3.2.1.3. Section 117 Aftercare Meetings

3.2.1.4. Adult safeguarding enquiries and meetings

3.3. For people at risk of Multiple Exclusion Homelessness, what learning can be identified from Joe’s circumstances for partner organisations, regarding provision and accessibility of sufficient and suitable accommodation, in line with relevant Housing duties and responsibilities

3.3.1. Housing Act (1996) duties

3.3.2. Mental Health Act (1983), Section 117 Aftercare duties

3.3.3. The Care Act (2014)

4. Findings and recommendations from the review

Recommendation 1.

Recommendation 2.

Recommendation 3.

Recommendation 4.

Recommendation 5.

Recommendation 6

Recommendation 7