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SAR June

1. Introduction

June, a white British lady, died at her flat on 11 April 2022. She was 58 years old. June was found unresponsive on her bed by her partner who had visited her. She weighed 30kg (4.7 stone). The post-mortem determined the cause of death as starvation due to or as a consequence of self-neglect. June’s self-neglect is the focus of this review.

On the 1 and 6 April 2022 following 999 calls the ambulance service responded to June after concerns were raised by her partner and mother that June could not walk, was intoxicated and eating insignificant amounts of food provided by her partner. Ambulance staff described her as significantly emaciated. Poor personal hygiene and toileting habits were also recorded – June was wearing her coat, sat in her bed, in her own faeces.

A GP from the local surgery also went to her flat on the 6 April. The GP found June had low blood pressure and a rapid pulse. The GP noted that she was extremely thin, weak, and lethargic.

On both these occasions there were significant concerns from health professionals, June’s mother, and June’s partner that June needed medical support at a hospital. However, June refused to go to hospital, she wanted to stay at home and sleep. She was assessed by ambulance staff and a GP as having mental capacity to make the decision to stay at home. June said she was aware that the consequences of this decision could result in her death.

Her partner again attended her flat on the 8 April. June remained bed bound, as she had been for the last few weeks. Her partner spent an hour with her, talking and joking. From the records available, this was the last known recorded contact before June passed away.

A Safeguarding Adults Review (SAR) referral was received by Torbay and Devon Safeguarding Adults Partnership (TDSAP) on the 17 March 2023. The referral was made on the 10 March 2023, nearly a year after June died. The reasons for the significant delays in the SAR referral and commissioning process are covered in this report. An inquest into June’s death has not yet been held. The opening of the inquest is contingent on the publication of this SAR.

Andrew Bickley an independent lead reviewer for the SAR was appointed in February 2024. He has a background in UK policing having served to the rank of assistant chief constable with executive responsibilities that included adult and children’s safeguarding. Following his police career he has specialised in a variety of independent safeguarding roles; as an independent chair of local safeguarding children and adult partnerships, leading several safeguarding reviews within the Church of England and undertaking statutory reviews for individual children and adult safeguarding cases. He has no connection to any agency involved in this review.

Following an assessment of the SAR referral the TDSAP concluded that the circumstances of June’s death met the mandatory criteria for a SAR[1]. Such a review must take place in a case involving an adult in its area with needs for care and support (whether the local authority has been meeting any of those needs or not) where:

  • an individual has died (or been seriously harmed),
  • the death or harm is thought to result from abuse or neglect (including self-neglect) and
  • there is cause for concern about how agencies worked together to safeguard the individual.

The purpose of the SAR is to identify learning that can be used to improve future interagency practice and prevent future deaths or serious harm in similar circumstances. It has been conducted in accordance with section 44 of the Care Act 2014 and the TDSAP procedures and processes. The TDSAP wishes to express sincere condolences to the family and friends of June.

[1] Section 44 (1-3), Care Act 2014

2. Terms of Reference

2.1 The review focused the period from December 2021 to April 2022 to address:

  • What agencies knew about June’s history, home circumstances and how they engaged with her.
  • How issues of self-neglect were considered, approached, and responded to.
  • How agencies considered, approached, and responded to June’s mental capacity in relation to her health care and wellbeing including consideration of inherent jurisdiction.
  • The quality of multi-disciplinary safeguarding working including how information and risks were managed and shared.
  • How agencies undertook, assessed, and considered June’s care and support needs.
  • How agencies engaged with and considered June’s wishes regarding her safety and care and support needs.
  • Understanding the support June received from family and friends.
  • Establishing the views of June’s mother/significant others.
  • How the SAR referral process was managed and the reasons for the delay.

3. Methodology

The reviewer was supported by a SAR panel established by the TDSAP and chaired by a member of Devon and Cornwall police. The panel set the terms of reference for the review and provided oversight on the development of the report and recommendations.

The following organisations were represented on the panel:

  • Torbay and Devon Safeguarding Adults Partnership (TDSAP).
  • Devon Partnership Trust (DPT).
  • Glendevon Medical Centre (General practice).
  • Devon County Council- Integrated Adult Social Care (DCC-IASC).
  • Together Drugs and Alcohol Service.
  • Southwestern Ambulance Service NHS Foundation Trust (SWASFT).
  • Torbay and South Devon NHS Foundation Trust (TSDFT).
  • NHS Devon Integrated Care Board (ICB).
  • Devon and Cornwall Police (DCP).

Prior to the appointment of the reviewer, the TDSAP gathered a variety of information from agencies that had worked with June through single agency summary reports and individual management reviews (IMR’s). The scrutiny of this information by the reviewer helped to identify a chronology of key events and shape the analysis of multi-agency safeguarding practices for June. Additional information and points of clarification were requested from agencies by the reviewer who also held one to one meetings with representatives from agencies most involved with June’s care. This information gathering was further informed by research of national and local learning from cases of self-neglect and published literature. Of value was the opportunity to cross reference June’s case with the findings arising from the TDSAP commissioned thematic review on self-neglect. This review, published in February 2023 [2], examined the circumstances of six people who had died in 2019/20, where self-neglect had been a feature of their lives. It identified common learning and provided an insight into recurring, systemic issues which require attention in local safeguarding practice. A number of these issues also featured in the experiences of June.

The emerging themes identified from the scrutiny, analysis, literature review and previous learning were used at a bespoke learning event for agency practitioners and managers. This was a facilitated learning event which offered an opportunity for relevant partners to constructively share their insights and reflections on the services provided to June. Agencies also explored what could have potentially been done differently to achieve better safeguarding outcomes.

The learning in totality was analysed using an established evidence base for best practice in self-neglect This evidence base offers a framework for assessment and analysis of safeguarding policy and practice under five domains of the safeguarding system. The five domains are:

  • Domain A: Direct Work-How practitioners engage with individuals.
  • Domain B: Interagency Working-How practitioners from different agencies work together.
  • Domain C: Organisational Considerations-How organisational features and systems influence the work that is done.
  • Domain D: Governance-How the Safeguarding Adults Board or Partnership exercises its multiagency leadership role.
  • Domain E: Policy-How national factors such as law, policy and the work of national bodies influence local safeguarding- (note national policy issues were not relevant to June’s case and were not used for analysis in this report).

This analytical approach mirrors that used in the TDSAP thematic review of self-neglect cases referenced previously in this report. Utilising this methodology for June’s case supports the Partnership to more readily align the compelling changes needed in self-neglect practice and policy, building on the implementation of the lessons learned in the local thematic review.

It also offers a benchmarking approach to evaluate practice in June’s case as well as being recommended SAR practice in the landmark studies, ‘Analysis of Safeguarding Adult Reviews April 2017- March 2019’ and the second ‘Analysis of Safeguarding Adults Reviews (SARs) April 2019- March 2023’.[3]

There were limitations with this methodology. Collating information for the SAR was time consuming with no integrated chronology of agency contacts and some agencies not initially approached for information, for example, the Department for Work and Pensions (DWP). The facilitated learning event took place over 2 years after June passed away. Only June’s GP remained as a professional who had directly worked with and supported her. All these factors combined to present challenges to the review process.

[2] TDSAP Thematic Safeguarding Adults Review – Self Neglect, Suzy Braye and Michael Preston-Shoot, February 2023.

[3] Landmark study-Analysis of Safeguarding Adult Reviews (SARs) April 2017-March 2019, Analysis of Safeguarding Adult Reviews (SARs) April 2019- March 2023, M Preston-Shoot et al

4. Agency involvement

The agencies involved in June’s case and referred to in the report are:

  • Torbay and Devon Safeguarding Adults Partnership (TDSAP): Referred to as the Partnership or TDSAP. The body responsible for assuring the provision of adult safeguarding services in Torbay and Devon. They have the lead governance role in the commissioning of the SAR process (Section 44 Care Act 2014).
  • Devon Partnership Trust (DPT): Providing mental health services-Emergency Department Liaison Psychiatry, community mental health teams including a Single Point of Access (SPA). Received referrals to support June’s mental health assessments.
  • Glendevon Medical Centre: June’s registered doctors’ surgery since 2018 with a named General Practitioner (GP) and support from GPs in the practice.
  • Devon County Council- Integrated Adult Social Care (DCC- IASC): Referred to as IASC. The providers of adult social services and decision makers for the safeguarding referrals made under Section 42 Care Act 2014.
  • Together Drugs and Alcohol Service: Referred to as Together. A charity commissioned by Public Health, Devon (County Council) to provide alcohol and drug harm reduction services. Undertook a comprehensive assessment of June’s alcohol use.
  • Southwestern Ambulance Service NHS Foundation Trust (SWASFT): Referred to as the ambulance service. Attended to June at points of emergency and crisis in her life.
  • Torbay and South Devon NHS Foundation Trust (TSDFT): The ‘acute trust’- providers of specialist NHS medical services through the Gastroenterology and Endoscopy department. Led the treatment for June’s oesophageal stricture from 2018.
  • NHS Devon Integrated Care Board (ICB): NHS organisation responsible for planning and commissioning of health services for the local population. They manage the NHS budget and are responsible for contract monitoring, governance and safety of the health services they commission, including hospitals and GP practices.
  • Devon and Cornwall Police (DCP): Referred to as the police. Attended the scene of June’s overdose in December 2021 and completed a vulnerability screening assessment (ViST).
  • Department of Work and Pensions (DWP): Provided welfare benefit payments to June.

The accommodation provider for June’s flat has not been established and therefore does not feature as part of this review.

5. Family participation

The Partnership wrote to June’s mother, and the only known next of kin, on the 8 February 2024. The letter was delivered by recorded delivery to her home address and was signed for. The letter set out the SAR process and requested contact be made with the TDSAP team. No reply was received to this letter.

A further letter was sent by recorded delivery on 8 April requesting contact with either the TDSAP or the reviewer whose direct contact details were included in the correspondence. The letter was ‘signed for’ but no contact was forthcoming. The absence of a family perspective and family insight on June’s life and experiences is regrettable.

June had a close friend/partner that visited her at her flat. However, they did not appear to cohabit and whilst he featured in her life, the extent of his contact and involvement is limited to the information provided by agencies during the review. For reasons of privacy, confidentiality and proportionality, no attempts have been made to speak with this friend/partner.

6. Biographical information

The validity of the following biographical information has not been confirmed with a family member. It is taken from a community mental health assessment record in 2016.

This assessment recorded that June’s father was in the RAF which led to the family living in different countries until she was 15 years of age, and they settled in Plymouth. Her father would drink heavily but she described having a good childhood with her brother and sister. She disliked school and on leaving went to secretarial college. She secured good jobs as a personal assistant and legal secretary until her alcohol use increased and she was no longer able to work. Her sister died at the age of 48 years due to an alcohol related illness. June never married nor had children.

June had been in a 20-year relationship with a male partner who abused her. The extent of this abuse resulted in her pouring petrol over him and setting him alight whilst he slept. June called the emergency services and was arrested and charged with grievous bodily harm. She was sentenced to 6 years in prison and served 3 years.

She had more recently been in a relationship with a man who lived locally.  When the relationship ended, they remained friends. June had been using alcohol for many years alongside a history of depression and anxiety and physical health difficulties.

Protected characteristics

The Equality Act 2010 ensures there is a framework of protection against direct and indirect discrimination, harassment and victimisation in services and public functions. Services must be delivered in a fair environment and comply with the law. The Equality Act references 9 protected characteristics, all of which must be considered when implementing safeguarding procedures and delivering the principles of Making Safeguarding Personal.

Other than June’s age and birth gender the extent to which other protected characteristics applied to her are not known. They did not feature in any of the records seen by the reviewer and without the insight of a close family member or friend, they cannot be established.

7. Relevant history prior to the time in scope (before December 2021)

June joined her local GP practice in 2018 where she remained a patient until her death. Her main GP had known her for 6 years and monitored her physical and mental health, providing continuity of primary care.

In 2018 the GP records identify that June had a long history of anxiety and depression, previous drug overdose and alcohol dependence. June also had an oesophageal stricture, a tightening of the tube that connects the throat to the stomach. The stricture was causing difficulty with swallowing and weight loss. Blood tests were consistent with alcohol dependence. She weighed fifty kilograms (7.9 stone) with a Body Mass Index (BMI) of 17 (underweight). A review with the community mental health team was also undertaken which recorded fluctuating but well controlled levels of anxiety. At this time June was in a long-term relationship, compliant with her medication and her drinking was under control.

In 2019 June took an overdose of her prescribed medication and alcohol. At the follow up GP appointment she weighed 48 kgs (7.56 stone) and was drinking three cans of lager a day. Thiamine and vitamin B were additionally prescribed. She was also referred to RISE, a drug and alcohol service but did not attend the appointment in January 2020.

In 2018 and 2019 June attended two endoscopic dilation therapies and had a subsequent clinical review with a consultant gastroenterologist. This review described an excellent symptomatic response. She was left with an open appointment for further procedures as needed.

In July 2020, a referral was made by her GP to Torbay Hospital (the endoscopy and gastroenterology department)for an endoscopy. This was upgraded following a review for a gastroscopy and dilation, to be completed in 2 weeks. This 2-week triage was delayed due to Covid-19 pressures prevalent at the time. Clinicians note that this did not impact on June’s subsequent treatment.

The endoscopy procedure was successfully completed in August 2020. Advice was given to the GP about medication and a repeat procedure was arranged in two months to reassess her. Following the procedure June went home alone in a taxi, against medical advice. June’s propensity to self-determine was a feature of her response to medical advice and treatment throughout her engagement with health partners.

In November 2020 and February 2021, June rang and cancelled the repeat endoscopy procedures, the latter cancellation due to her contracting Covid-19. She was subsequently removed from the waiting list, a standard practice after 2 cancellations, and returned to the care of her consultant.

June’s consultant then began to manage her treatment through telephone clinics and assessments. Telephone assessments were a feature of practice with the Covid-19 restrictions in place on visiting hospitals. The first assessment was undertaken in April 2021, and it was noted that swallowing for her remained an issue but that she was managing soft foods. Gastroscopy and dilation were requested following the consultation. The GP and June were updated by letter on the outcomes and plans for her treatment.

In three consecutive months from April 2021, June called the endoscopy booking team cancelling her appointments. In June 2021 her consultant attempted a telephone assessment but was unable to reach her. He followed this up with a letter to June and her GP, expressing concerns that delays may cause significant swallowing issues. Contact details for the appropriate team for June to contact were provided and advice offered on how to manage excess acid with medication. She was advised to contact her GP to access further dilation treatments.

In July 2021, June contacted the endoscopy booking team and cancelled her further appointments as she did not wish to proceed with any more procedures. She was removed from the waiting list. Her consultant wrote a further letter to June and her GP acknowledging that June did not wish to proceed and offered his direct contact details. At this point, she was discharged from this service. Clinicians noted in their submission to the SAR that there was nothing that would suggest anything other than a standard care pathway was appropriate for June.

8. Key events in scope (December 2021 – April 2022)

On the 10 December 2021, the ambulance service responded to a 999 call for June who had taken an overdose of prescribed tablets (chlorpromazine and mirtazapine) and drank a quantity of alcohol as well as expressing suicidal thoughts. She was in bed, alert and engaged with the ambulance crew who attended to her. Her partner was present. June was taken to Torbay Hospital. The ambulance personnel made a referral to the GP for mental health support.

The police also attended this incident. A police vulnerability screening assessment was completed (ViST form) which comprehensively identified June’s vulnerabilities and highlighted areas of concern. These were recorded as a ‘medium risk.’ This form was then reviewed by a Central Safeguarding Team within the police who assumed the information would be shared with relevant partners by the medical professionals. This was an incorrect assumption.

The following day the Liaison Psychiatry team in the Emergency Department at Torbay Hospital assessed June. It was recorded that June drank six cans of Stella Artois alcohol a day. She planned to start Cognitive Behavioural Therapy (CBT) having previously had three sessions prior to Covid-19 lockdowns. June was experiencing stress factors at the jobcentre who were encouraging meaningful job activity whilst she struggled leaving the house with her anxiety issues. She denied any ongoing suicidal ideation or negative thoughts and provided evidence of forward planning. A request was made for the GP to review her medication and check her health and diet.

June agreed to a referral to Together Drugs and Alcohol Service. At this time, her ambivalence toward cutting her alcohol use was noted on her records. She was referred to the Together service on the 22 December 2021. The referral was screened and allocated to a remote agency recovery worker on the 21 January 2022. This was followed up with a letter to June three days later, confirming the appointment arrangements for her assessment.

Together used remote agency recovery workers to manage service caseloads and cover gaps in their staffing profile. These workers worked remotely, not ‘in person’ with clients, continuing practices established during Covid-19. June was provided with continuity of care from her recovery worker for the duration of her case being open with their service.

On the 4 February, the Together service made a call to June as she did not attend the meeting for the comprehensive assessment. A new date was set. Further calls were made for the assessment meeting on the 7, 11 and 17 February. On each occasion June stated that she was still too unwell for the appointments to take place. The Together service offered a food parcel which June declined and made welfare (phone) calls to her. June was also encouraged to arrange a GP visit.

The comprehensive assessment was completed on the 25 February over the phone. As no additional concerns or risks had been flagged for June, conducting an in-person assessment was not a consideration for the Together service at this time.

During the assessment it was noted that June’s speech was slurred. She recorded the lowest scores possible for her mental health, physical health, and well-being (1/20). The assessment findings included:

  • June drank eight cans of Stella daily from 0900-2100 and had done so for last 14 years.
  • Noting that periods of morning delirium and shakes were not uncommon for her.
  • She ‘feels like she wants to die all the time, not suicidal just despair.’
  • A safeguarding concern that her partner supplies the alcohol.
  • A safeguarding concern based on a debt of £20,000 for which she was paying off £50 per week.
  • June would not be suitable for group work or workbooks to address her alcohol use.

A treatment plan was established and a ‘Healthier Me’ review was suggested but it is not clear from the case notes if this review was completed. Following the assessment an e mail was also sent to her GP asking for a face-face appointment to be held, given Junes mental health assessment score of 1/20 and June complaining of flu-like symptoms for 4 weeks. The GP responded by acknowledging they shared common concerns, but that June would not attend appointments.

On the 28 February, further welfare support phone calls were made by Together to June. She confirmed a GP appointment had been booked. Alcohol harm reduction advice was given, and the value of thiamine being prescribed was highlighted to her. Useful contact numbers and signposting for other support agencies were also shared with June by phone and text messages.

In February 2022 June’s mother approached the GP concerned about June’s weight loss. The GP spoke with June on 25 February as she had noticed that she had cancelled her appointment for routine blood tests and wanted to check her blood pressure and weight. June told the GP she had flu but would come to the surgery during the following week. The GP offered district nurses to visit June to take blood tests and weigh her, but she gave assurances that she would come to the surgery. An appointment was made for the 2 March with a follow up call made by the surgery to remind her of this appointment. The GP also reviewed the endoscopy treatments noting that June had cancelled several appointments.

June did not attend the 2 March GP appointment; a phone call was made to her the following day. She explained she still had flu but had done some shopping two days previously. Home visits by the GP or district nurses were again offered but refused. The GP established that June was eating soup, bread, and macaroni cheese. June thought she was about 8.5 stone at this time. June advised that she was drinking four cans of lager daily but was engaging with Together. She informed the GP that she would come for the blood test the following week and that she would also like a referral back to Gastroenterology Department for another dilation.

Due to her weight loss and difficulty with swallowing an urgent referral was made by the GP to the endoscopy team for this procedure to be undertaken. The referral was triaged as an urgent oesophago-gastroduodenoscopy (OGD) and dilation. However, it was not until the 28 March that a clinician from the team phoned June but this call was unanswered.

The GP also spoke to June’s mother who said she would bring her to appointment for the blood test the following week. June did not attend this appointment.

On the 3 March, the Together recovery worker sent an e mail to the GP raising concerns regarding June’s physical and mental health and the options for prescribing thiamine. Her GP replied that she was aware of June’s condition, and that June had been referred for an endoscopy. The GP asserted that June’s main problem was alcohol addiction.

On the 7 March, the Together recovery worker queried with the GP if an adult safeguarding concern had been raised. June’s needs at this time were perceived by the Together service to require medical responses as opposed to treatment for alcohol abuse.

Phone calls were made by Together staff to June during 8-14 March. These calls were either not taken by June or accepted by her phone.

On the 10 March Together held a Multi-Disciplinary Team (MDT) meeting which generated an action to speak with surgery. On the same day, the GP phoned June but the call went to answerphone. The GP noticed that June had not ordered her medication for over month.

On the 14 March, the Together service informed her GP that due to June’s lack of engagement her case would be closed. This was followed by a letter to June advising her of this outcome. The closure of the case was in line with policy at that time.

At this point her GP recognised that despite the support of the Together team, June had limited success with reducing her alcohol intake. Her stricture was affecting her food intake – which was limited to a diet of liquids and semi-liquids. June’s condition had deteriorated. She rarely attended GP or other medical appointments and the primary contact with her was limited to phone calls. The GP made an urgent referral to the Single Point of Access (community mental health team) on the 15 March 2022 for a mental health assessment and an urgent safeguarding referral was made by letter to social services.

The plan from the community mental health team was to arrange an urgent joint assessment with the Together Alcohol Service. There was a note recorded on the screening form for the team to notify the GP that, ‘any safeguarding concerns they may have needed to be acted upon without waiting for the assessment because joint assessments can take a longer time to arrange.’ It is not clear from the mental health team notes if this message was delivered to the GP.

The first contact received by Integrated Adult Social Care (IASC) for June was on the 16 March 2022 when the safeguarding concern was received from the GP. This concern highlighted the need for an urgent mental health assessment, due to the impact June’s mental health was having on her physical health and lack of engagement with health services. The referral was screened the following day against a RAG (red, amber, green) risk matrix (not against the Care Act 2014 criteria), to determine whether the concern should be addressed as a priority. It was rated as green/low priority and added to the safeguarding teams waiting list-no safeguarding issue was identified. The rationale for this was that professionals were awaiting a mental health assessment and that an alcohol team were supporting June.

16 days after the safeguarding referral was made, on the 1 April, IASC re-screened the concern and, on this occasion, recorded June’s case to be a medium/amber priority. It remained on the safeguarding teams waiting list. The rationale for this upgraded assessment was based on the mental health teams still trying to complete their visit to June. Of note, the safeguarding concern raised by her GP was never triaged and assessed against the Care Act 2014 criteria to determine whether it met the criteria for a statutory Section 42(2) safeguarding enquiry.

On 31 March the community mental health team sent a text to June asking her to contact them to arrange an assessment. This was over two weeks after the urgent GP mental health assessment referral was made. However, as the original referral was not highlighted as an immediate risk i.e. a threat to life, it did not meet the threshold for a speedier response from the community mental health team.

On the 1 April 2022, the ambulance service responded to a 999 call from June’s mother to June. June’s mother reported that her daughter could not walk or eat and was intoxicated. According to ambulance service records, June had been losing weight over the last year. She had been unable to mobilise for the last 5 days and had been weak for much longer. She was in bed and looked significantly emaciated. Poor personal hygiene and toileting habits were noted. Alcohol and tins of soup were seen in the kitchen. The house was cold. Ambulance staff wanted to admit her to hospital – due to her immobility and safeguarding concerns. However, June declined to be taken to hospital. She was considered to have mental capacity to make this decision by the ambulance staff.  SWAST raised a safeguarding referral which was sent to her GP.

Her GP followed up this incident with a phone call to June on the 4 April but received no answer to the call. Her GP followed up her safeguarding referral made in March to social services. A message was left for the IASC safeguarding team to call back. No response was received to this call.

On the 6 April, the ambulance service responded to another 999 call to June again made by her mother who had found June sitting on the bed in her own faeces and unable to mobilise. June was described as looking ‘grey’ but was fully alert. The ambulance crew recorded that June had mental capacity and passed the mental capacity test. However, it’s unclear what this test was. June said she understood that if she did not go to hospital she would die. June refused to be taken to hospital. She wanted to stay at home and sleep. Subsequently, the ambulance team requested the attendance of a GP. Fluids were administered and a safeguarding referral for IASC was completed by the ambulance staff.

The GP that attended from June’s surgery noted that she was extremely thin, lying on faeces-stained sheets and had poor dentition (few teeth). She was alert, her speech was normal, but her blood pressure was extremely low and pulse rate rapid. The GP informed her that she was not able to explain the cause of the low blood pressure and weight loss, which could have been due to an infection or abnormal kidney function. June said she always had low blood pressure and just needed to sleep to feel better. She would not go into hospital.

The GP directly asked June if she understood the consequences of her decision (to not go to hospital) and she said yes, she was aware she may die. June was prepared to accept this and would not go to hospital. In discussion with June’s mother, the GP notes that she said June knows her own mind and has always been and behaved like this. June’s mother asked if June could be sedated but it was advised this was not possible without June’s consent.

The GP assessed that June had mental capacity. June stated she was aware of the consequences of remaining at home and not receiving hospital treatment. All efforts at persuasion were unsuccessful and June remained at home. The GP contacted the community mental health team to see if they had accepted the referral made previously and requested a call back. No follow up actions were recorded on the case notes held by the community mental health team. The GP received no update following this further contact.

IASC were also contacted on 6 April by June’s mother via Care Direct. She was concerned for her daughter’s welfare as she had arrived at her house and found her in agony, unable to walk. The bed was a mess and soiled. IASC managerial discussions were held the following day with a decision for June’s case to remain at an amber/medium risk grading. On this occasion, June’s mother was identified as a protective factor. Advice was offered to the GP to escalate concerns with the community mental health team. IASC also undertook to revisit the screening of the case the following week.

On 7 April, the safeguarding referral from the ambulance service (6 April) was received by IASC. A message was sent to an IASC team manager informing them of the ambulance service referral. The case was allocated to Social Care Assessor in IASC on the 12 April, the day after June died.

9. Thematic analysis

This section reports on the findings of the review organised in four of the five safeguarding domains. Within each domain, the key themes contributing to June’s care, support and safeguarding needs are considered to offer insight into practice and policy.

Domain A: Direct practice- How agencies engaged with June

Effectiveness of meeting health and social care needs

There were examples of good practice found in the review. June’s GP offered continuity of care and supported her medical needs in a relationship the GP described as trusting. Indeed, her GP was the fulcrum for several elements of good practice including:

  • Repeat referrals for treatment and ongoing monitoring to manage her oesophageal stricture and mental health.
  • An expedited referral for an urgent mental health assessment.
  • The medical considerations for blood tests, the need to weigh June and recognising need for additional vitamin intakes.
  • Establishing who was shopping for June and her food provision.
  • GP relationship with June’s mother – attempting to use her to support attendance for appointments.
  • Making a safeguarding referral for self-neglect based on June failing to attend medical appointments, poor engagement with services, weight loss, poor mental health, and alcohol use.

The medical care provided to June by Torbay Hospital Gastroenterology and Endoscopy Department from 2018 onwards was thorough and responsive to GP referrals to dilate and monitor her oesophageal stricture. There was only one exception to this – her GP referral for an urgent endoscopy dilation made on 3 March, was not responded to by a clinician until an unanswered phone call was made to June on the 28 March.

There was good liaison and communication between the GP and Endoscopy team throughout her treatments. Clear assessments and management plans were provided by clinicians to both June and her GP.

Letters, phone calls, text messages were routinely transacted to June for missed appointments from a range of services including Endoscopy services, GP, Together, and the community mental health team. On one occasion, to emphasise the importance of having the dilation and the significant risk in not doing so, a consultant gastroenterologist gave his direct contact details in a letter to June.

The Endoscopy booking team demonstrated good recording practices of June’s contact with the department and clearly documented the escalation of June’s missed appointments to a clinical lead.

Liaison Psychiatry completed a detailed assessment in December 2021 with clearly defined next steps in terms of a GP led review of medication, health, and diet. A referral to Together Drug and Alcohol service was also made recognising the prominent role of alcohol in June’s life.

Together undertook a detailed assessment of June’s alcohol dependency and plans were put in place to manage the risks. Welfare considerations were routinely made by the Together staff following the assessment including offering a food parcel. They also offered more appointment opportunities (four) for June to complete her comprehensive assessment than was the policy at the time (two appointments).

However, there were significant shortcomings which led to June’s health and social care needs being unmet despite engagement with key services throughout the months prior to her death.

Care and support needs assessment

Despite June’s questionable ability to manage tasks of daily living no section 9 Care Act 2014 care and support needs assessment [4] was ever undertaken for June even in the final weeks of her life. It does not appear one was suggested at any time by any agency. No care package was in place when she died. Indeed, IASC had no prior involvement with supporting June until the safeguarding referral was made in March 2022.

Any agency involved with June could have proactively requested this assessment and potentially ensured the coordination of care with a range of other agencies. However, it’s unclear if June would have accepted a community support package or if such a measure would have altered the outcome.

Mental health assessment referral

In 2022, the Single Point of Access for mental health teams provided a centralised way to coordinate mental health assessment referrals. These teams would make an initial contact with a patient, allocate cases to assessment workers and coordinate responses to referrals. Immediate actions would be initiated if there was an imminent (immediate) threat to someone’s life presented in the referral. An urgent referral would be responded to within 1-2 weeks and a non-immediate/urgent referral would be held on a waiting list for an assessment which could, in 2022, take 12-18months to complete.

The GP referral for an urgent mental health assessment did not lead to any immediate actions as there was no indication in the referral that June’s life was at risk – the threshold for immediate action was not established in the mental health referral process. However, the GPs expectation was that immediate action was necessary and had been requested through the urgent nature of her referral.

Despite the GPs expectations, the mental health service responded to the urgent referral, twenty days later, by directly texting June and asking her to contact the team to arrange her appointment. There does not appear to have been any consideration for in person visits or joint agency approaches to pursue the urgent referral.

Further, there was no appreciation of June being able to use this pathway – did she have the cognitive and physical ability to make connections with other organisations and understand the need to arrange her mental health assessment? Sending isolated texts to a patient who is self-neglecting before a preferred method of communication had been established and proven with them, is not an effective practice.

Professionals reflect that June’s case would have benefited from personal conversations between the community mental health team and GP to develop a shared understanding of her deteriorating situation and the desperate need for her mental health to be assessed. The fact that the GPs follow up contact to the mental health team on the 6 April went unanswered further compounded the understandable sense of frustration and isolation expressed by the GP during the review.

Additional considerations which arose at the learning review and in subsequent meetings with the reviewer were the potential benefits of requesting a Mental Health Act (1983) assessment [5] as opposed to a mental health assessment which had been sought by the GP in this case. The GP was cognisant that June had a history of being under mental health services and was on several mental health medications when she initially transferred to the surgery. Although June didn’t express she was depressed or display a particular mental illness the GP was concerned about her self-neglect and the inconsistencies in what she expressed and what she did i.e. committing to appointments but then not attending them.

However, a mental Health Act (1983) assessment would have been undertaken more quickly, in a matter of days. This type of assessment primarily focuses on the statutory need to potentially detain a person for treatment and convey them to a place of safety using provisions, for example, under Section 135 of the Act (the granting of a warrant by a Magistrate giving the police a power to enter homes, if need be, by force, if someone is at risk of seriously harming themselves or others). These considerations could also have usefully informed decision making on June’s mental capacity, which is covered later in this report.

Reluctance to engage

There are several issues to consider in terms of how agencies responded to June’s reluctance to engage with services. The majority of follow up medical procedures and appointments for a range of services (GP, Endoscopy, Together, mental health) were cancelled, declined, or ignored by June. Her non-attendance at prearranged medical appointments, organised to support her health needs demonstrated a pattern of behaviour over several years. This consistent non-attendance was not seen by any agency as self-neglect until a month prior to her death, when the Together service and GP shared concerns and the GP used the lack of engagement with health services as a factor in raising a safeguarding concern for self-neglect.

Whilst June’s poor engagement with health services was problematic, following up her missed appointments by letter, text, or phone messages proved to be an ineffective way to engage with her. This was brought into a sharper focus between February and April 2022 when there was greater visibility on the scale of her self-neglect and deteriorating mental and physical health. Learning from national reviews demonstrates that in self-neglect cases, letters may be hard to read, cause anxiety or be added to a pile of unread posted mail.

People that are self-neglecting need face to face encounters with professionals to ensure that there is a full appreciation of their circumstances and to allow an opportunity for greater insight and empathy for their situation. Research [6] has emerged about social work responses to self-neglect during the Covid-19 pandemic, emphasising the importance of face-to-face visits to people self-neglecting.

There were potentially too many assumptions in June’s case with the way her non-attendance was managed by partners who applied a ‘one size fits all approach.’ These assumptions may have been informed by a belief that June was making a capacitated choice when cancelling, declining, or not turning up for appointments and did not consider factors such as the impact of her alcohol addiction, her fragile mental health and declining physical health.

June’s non-attendance at appointments, limited face to face contact with agencies as well as a lack of visits to her home made the deterioration in her wellbeing, living conditions and underlying health issues less visible until her in-person GP appointment at the medical centre in early March 2022. At this point home visits for the purpose of blood tests and weighing by the GP or district nurses were suggested to June but declined by her. Following concerns raised by June’s mother home visits were made by the ambulance service on receipt of 999 calls, days before June died.

On these occasions, there is some recording of home conditions and notes provided by her GP and the ambulance service describe how June was manging her care, personal hygiene, and shopping. This information was ultimately used to inform the safeguarding referral. However, home visits did not feature as part of any agencies routine practice and appear to have only occurred at points of crisis in June’s life.

Good information gathering can help establish the most appropriate ways to engage with and support an individual. For example, who in her family or social network may have been available to help to support attendance at appointments, advocate, or influence them are key considerations. In June’s case her partner does not appear to have been utilised for this purpose. The GP sought mothers help for securing June’s attendance for an appointment on one occasion. But such approaches do not appear to have been considered by any other services and joint agency approaches or visits were not pursued.

A self-neglect thematic SAR review commissioned by Hampshire Safeguarding Adults Board [7] highlighted in cases of self-neglect, meetings outside of a person’s home and working outside of usual hours should be considered. Systems need to be flexible and provide for personal visits and follow ups, rather than just automatically rebooking appointments or trying to contact by letter, phone, or text.

Sharing of information and joint working with partners can also help to identify windows of opportunity to reach individuals. Valuable opportunities can be presented when a person is out of their usual environment and in hospital or is recognising the need for help as June did on some occasions, or when an emergency service has managed to get inside the door.

At the learning event creative opportunities to better engage with June were explored. DWP appointments usually have a high attendance by clients in receipt of their welfare benefits. The DWP whose service includes a vulnerable client’s team, would, support hosting or attending joint agency appointments including with GPs at their surgery.

It was also highlighted that in self-neglect cases, the fire and rescue service can offer fire safety assessments on the home environment which could offer additional opportunities to support adults at risk of self-neglect. In June’s case, her alcohol dependency, smoking and immobility does indicate a vulnerability to fire hazards in her flat which could have influenced decision making on her care and been opportunity to formally engage the assistance of the accommodation provider.

However, it was acknowledged by agencies at the learning event and in discussions with the reviewer, that the completion of a Section 9 Care Act 2014 care and needs assessment, a multi-agency risk management forum or the initiation of a Section 42 Care Act 2014 safeguarding enquiry are all processes which would have offered the potential for multi-agency problem solving to secure better engagement with June. Adopting the Section 42 safeguarding enquiry pathway could have led to June accessing an advocate and potentially mitigated some of the engagement challenges services experienced with June.

It must also be recognised, when considering more creative ways to engage with individuals who are reticent to meet professionals, practitioners do need clear guidance on the risk and rights to resolve the ethical challenges of balancing a person’s rights to privacy with the duty of care to uphold all human rights including the right to life. Bray et al (2017) [8] note that practitioners who work with people who self-neglect may struggle to manage the tensions between respect for autonomy, self-determination, and the legal duties to safeguard and protect, which can then result in practitioners failing to employ respectful challenge and concerned curiosity.

Mental Capacity

June’s mental capacity was specifically referred to by services on three occasions. The Endoscopy team record that for their procedures consent is obtained and documented for June which would include an assessment of capacity to understand and retain information and the rationale (for the procedures).

On the 1 April, in response to the 999 calls from June’s mother, ambulance staff recorded concerns on her physical health and weight loss, personal care and hygiene and living conditions. Ambulance staff wanted to admit June to hospital due to her immobility and the safeguarding concerns. June refused to go to hospital and the ambulance staff considered her to have the mental capacity to make this decision.

Following another 999 call on the 6 April, the ambulance service again attended June’s flat and recorded concerns for her physical health, wellbeing and living conditions. June again declined to be taken to hospital. The ambulance crew recorded that June had mental capacity and passed the mental capacity test. However, it’s unclear what this test was. She was asked if she understood the consequences of her decision; she was aware she may die. The ambulance staff also requested a GP visit and attend to June. A GP from June’s medical centre attended and again explored with June if she understood the consequences of her decision not to go to hospital. June said ‘yes’, she was aware she may die. June was prepared to accept this and would not go to hospital. In discussion with June’s mother, the GP notes that she said June knows her own mind and has always been and behaved like this. June’s mother asked if June could be sedated but it was advised this was not possible without June’s consent.

The GP assessed that June had mental capacity and was aware of her decision and the consequences of this. All efforts at persuasion were unsuccessful and June remained at home. June was found deceased in her flat five days later.

During the review, at the learning event and in follow up communication June’s GP affirmed that her mental capacity had been sufficiently tested and that June was able to understand the information relevant to her decisions, was able to retain and use that information, and could communicate their decision(s), all requirements of capacitous decision making within the Mental Capacity Act 2005.

Assessing mental capacity for an adult presenting as June did is a complex undertaking and provides a significant challenge for professionals. However, opportunities provided by the review for deeper reflection and learning should not be overlooked, particularly in the light of experiences from other cases, legal reviews, and legal advice in the time since June’s death.

Practitioners can be reticent of limiting a capacitated person’s ‘right to make unwise choices and this common misconception of the Mental Capacity Act legislation creates the incorrect idea that adults have ‘a right to make an unwise choice’. It is unhelpful to adopt the view that an adult who is self-neglecting is making a capacitated choice.

June was assessed by both the ambulance service and attending GP to have mental capacity, a foundational principle under the Mental Capacity Act 2005, in the days before she died when she was emaciated, immobile and no longer able to take care of her personal hygiene. The ambulance service and GP who attended to June on the 6 April clearly recognised the risk that remaining at home, avoiding hospital treatment, was potentially fatal. Indeed, June passed away a few days later (11 April).

The GP reflections highlight that no follow up visit was arranged in the days between June’s decision to remain at home and the day she died. It was not felt that June’s death was imminent; urgent referrals had been made to other services; and it was known that her mother and partner were still around.

The ambulance service submissions to the review and those of the attending GP set out their considerations on mental capacity. Whilst June’s mental capacity was considered, what is less clear is the actual process undertaken for assessing whether June had mental capacity to decide (to avoid medical treatment at the hospital) and the recording of the conclusion reached on June’s mental capacity, with the supporting rationale. No formal assessments appear to have been undertaken.

A mental capacity guidance note from 39 Essex Chambers (March 2023) is instructive in this regard [9]. At the learning event it was advised that June’s medical notes were used to capture the capacity discussions. However, there is no record provided to the review which shows how and to what depth June’s ‘executive function’ (her ability to carry out a decision) or potential ‘executive dysfunction’ were assessed in the context of her situation and the gravity of her presenting circumstances. What questions were asked, how they were considered and how the responses were recorded did not form part of a formally recorded assessment, completed contemporaneously. If the focus is only on a person having decisional capacity, we will not understand a person’s ability to carry out their decision (executive capacity) and what prevents them from doing this.

Similarly, there appears to have been no record used to detail the considerations of the duty under article 2 of the European Convention on Human rights (ECHR) to take practicable steps to secure the life of a vulnerable person.

The learning event identified two other approaches that could potentially have been considered at this juncture of June’s care. Firstly, the local authority duty to assess the care and support needs of a person, without their consent under section 11 Care Act 2014, if it believes the person is experiencing, or at risk of, abuse or neglect.

Secondly, the application of inherent jurisdiction- essentially the ability of the High Court to make declarations or orders to protect adults that have mental capacity. This approach would require additional legal support and guidance for practitioners to activate but was suggested as another potential strategy.

Participants at the learning event recognised that to enable professionals to further explore mental capacity defined forward pathways and escalation processes are required to access in service or multi-agency expertise.

GPs did seek support from mental health services through an urgent referral for a mental health assessment and followed this up when they received no response to their request. Completing this assessment or exercising powers under the Mental Health Act 1983 of treatment in a place of safety could have made a significant contribution to the rigour and exploration of opportunities to formally assess June’s capacity. Ultimately, it may have made no difference to the outcome for June but the fact that this didn’t take place is a missed opportunity and one which the partnership needs to learn from.

There is extensive evidence from previously published SARs on self-neglect, that enhanced legal literacy, as well as creative learning and development opportunities, managerial supervision, multi -agency support and challenge can help professionals to be more curious and confident in the application of the broad range of requirements under the Mental Capacity Act 2005 and Care Act 2014. These themes are equally relevant to this case.

Safeguarding

There are aspects of good practice that emerge from this case from individual agencies.

The police vulnerability screening process recorded a comprehensive list of adult safeguarding risks on their ViST form in December 2021.

The Together assessment in February 2022 highlighted potential safeguarding risks to June by her partner buying her alcohol and the fact that June was managing a significant debt (£20,000). Together also followed up with the GP the need to raise a formal safeguarding concern.

Similarly, the community mental health team reflected the need for the GP to raise a formal safeguarding concern rather than waiting for the mental health assessment to be concluded before doing so.

Following the Together alcohol assessment several welfare calls were made to June by Together staff which included reinforcing the need for a GP appointment. Together also have a dedicated safeguarding lead for each of the three geographical areas they cover in Devon, a specialised resource available to support staff managing safeguarding concerns.

In March 2022 her GP raised both a safeguarding concern and the need for an urgent mental health assessment. The GP was also responsive to wider safeguarding concerns recognising the poor engagement with the Together service, missed medical appointments, weight loss, dietary needs. Her GP offered home visits to take blood tests and weigh June.

Ambulance service staff signposted mental health services following June’s overdose in December 2021. They also raised a safeguarding concern clearly recognising June’s self-neglect and GP referrals for additional mental health support in the 10 days prior to June’s death.

However, there were also some significant shortcomings in respect of how June was safeguarded. Although the Together comprehensive assessment highlighted two specific safeguarding risks for June with her partner supplying alcohol and June holding a significant financial debt (£20,000) which she was paying off at £50 per month, there is no clarity on action taken to understand and address these issues, other than potentially a cursory discussion with June. DWP also have no records of this debt or how it was being managed.

Crucially IASC recognise that opportunities to safeguard June were missed in not pursuing a Section 42 safeguarding enquiry under the Care Act 2014 when they received the safeguarding referral from the GP on 16 March (referral made by the GP on 10 March), phone contact from June’s mother on 6 April and a further safeguarding referral from the ambulance service on 7 April.

Following receipt of the referral a Care First record was created as June was not previously known to Devon IASC teams. When the concern was screened against a risk matrix, it was not identified as a priority safeguarding concern based on the partial information used by IASC. The screening process recorded that June was waiting for a community mental health assessment and that an alcohol team were in place. The concern was not reviewed for sixteen days until it was re-screened to an amber/medium priority on the 1 April 2022. This decision was partly informed by a judgement that June’s mother was a protective factor. The concern was never triaged against the Care Act 2014 criteria to determine whether it met the threshold for a for a Section 42(2) Enquiry.

During this time June’s self-neglect was acute and a decision to commit to multi-agency information gathering (Section 42(1)) or a safeguarding enquiry (section 42(2)), would have provided a statutory framework to coordinate multi-agency responses, and develop a holistic consideration of June’s care, support, and safeguarding needs, supporting the extensive efforts and work of her GP.

The IASC internal review records highlight oversights that featured in their management of safeguarding including:

  • Not effectively addressing the risks identified nor monitoring and reviewing risks in collaboration with other agencies during the time the concern was held on their waiting list.
  • Whilst the cross referencing of partners recording systems was detailed, this was not supported with verbal or written communication between IASC and other agencies to allow risk monitoring of the case and collaborative working.
  • Offering no clear recorded rationale for the risk rating and risk management of the safeguarding referral.
  • Concern around June’s capacity was not reflected upon at point of referral or followed up with her GP.

These factors combined to mitigate against multi-agency opportunities to explore sustained, preventative, and protective safeguarding work with June. If the high-risk self-neglect had been identified at the point the safeguarding concerns were raised and the escalated with partners, interventions and risk planning could have been actioned more effectively to address June’s significant safeguarding needs in the weeks before she died.

It should be recognised, as reflected in the Hampshire SAB thematic review on self-neglect, that how self-neglect and its associated risks are understood from a safeguarding perspective, are areas which are problematic nationally.[10] Professional curiosity, understanding and using legislation correctly, as well as creative partnership working have been identified as important in national research.[11]

Current statutory guidance [12] advises us that ‘it should be noted that self-neglect may not prompt a Section 42 Enquiry. An assessment should be made on a case-by-case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour.

There may come a point when they are no longer able to do this, without external support. However, an adult that meets the criteria for a Section 42 Enquiry should always be considered under the Section 42 duty. This duty offers a statutory framework including duties for agencies to cooperate and the duty to commission advocacy when a person has no representative and would experience substantial difficulty in being involved in their own safeguarding. Fully utilising the duties under Section 42 of the Care Act 2014 may have contributed positively to June’s care and support and provided the professional support her GP was actively trying to access.

Responding to alcohol use Alcohol was a key feature in June’s life, and she misused it daily. Her alcohol dependency was proactively addressed by services who referred her for treatment i.e., A GP referral was made to RISE, a drug and alcohol service in 2019 although she failed to attend this appointment. The GP records show that at her appointment’s alcohol use was discussed and considered.

Liaison Psychiatry referred June to Together drug and alcohol service in December 2021 which resulted in the completion of a detailed assessment (February 2022) and understanding of the role of alcohol in June’s day to day lifestyle and at points of crisis when used to overdose. The assessment recorded heavy alcohol consumption, (8 cans of Stella a day) although her GP records June as saying she was drinking 4 cans of lager daily in March 2022. The Together management plan included signposting support to other agencies, harm reduction advice, and a GP led review of prescribed medication.

The Together service is client led and dependent on the client positively engaging with recovery workers and ideas to improve their relationship with alcohol. This requires establishing a trusting relationship between professionals and clients. June only worked with Together for 6 weeks which precluded this type of relationship being formed. As a result, the drivers for her alcohol use do not appear to have been explored or understood, the focus remaining on helping her manage its effects rather than its cause.

DOMAIN B: Inter agency working – how practitioners from different agencies worked together.

Information sharing

Sharing of information in a timely way is crucial to the effectiveness of both interagency and single agency working and safeguarding practice. June’s case highlights some elements of good practice. The results of endoscopic tests were clearly and routinely shared with the GP including June’s failure to respond to follow up appointments, which ultimately provided evidence for her GP to make a Section 42 safeguarding referral.

Liaison psychiatry shared a detailed assessment with her GP and the Together drug and alcohol service following her overdose in December 2021. Both the community mental health team and the Together service shared with her GP the requirement for a safeguarding referral to be made and not delayed. The Together team and GP had two-way communication, sharing concerns, and prompting ideas on how best to manage June.

The ambulance service shared information on how June was caring for herself, what provisions she had in her kitchen, even noting the absence of ‘Complan’, which had been recommended by her GP. The ambulance service also secured GP attendance at June’s flat, sought additional mental health support and made a safeguarding referral to IASC.

However, there were also gaps in the sharing of information. The police vulnerability assessment (ViST) completed in December 2021 was not shared with partner agencies. The police attended at the time of her overdose in support of ambulance trust colleagues. The attending officer correctly identified June’s vulnerabilities, comprehensively highlighting the areas of concern. This information was subsequently reviewed and assessed by a central team who decided that the information will not be shared with partners based on the assumption that this would be a responsibility which rested with health professionals. The police recognise this was a deviation from organisational practice and guidance in place at this time.

Care Direct did not alert the IASC Safeguarding Hub to the call from June’s mother on the 6 April thus delaying intervention or the escalation of the concern. Re-consideration and re-prioritising of the risk was delayed until the subsequent referral from the ambulance service came 24 hours later.

There is no record of a response to the GPs follow up email after her referral for an urgent mental health assessment was made. Similarly, the GP had no reply to her follow up phone call to IASC after she had made a safeguarding referral.

It is evident that June’s GP was actively sharing information with other agencies and trying to engage services to address June’s significant safeguarding and care needs. Regrettably, the information shared was not effectively managed, assessed or responded to by other service providers, to the detriment of her care in the weeks before her death.

Interagency referrals

At certain points in June’s case there is evidence of good practice with agencies raising referrals with other agencies including:

  • Referrals for alcohol treatment and support, mental health assessments following moments of crisis for June, endoscopic treatments, and GP referrals.
  • The Section 42 safeguarding referral.
  • Referrals which recognised the need to review prescribed medication, dietary considerations.
  • The Together and community mental health services also prompted the submission of a Section 42 safeguarding referral in communications with her GP.

However, there were also missed opportunities for inter-agency referrals as well as fundamental shortcomings in the way some referrals were managed and responded to. Despite concerns about June’s immobility, lethargy, and propensity to remain at home in a deteriorating physical condition no consideration appears to have been made to refer for a fire safety risk assessment. June represented a potential safety concern in response to fire hazards and her ability to exit the flat. There is no visibility on the provision of fire alarms, how she cooked, the condition of sockets, the provision of portable heating or her smoking habits.

There do not appear to have been approaches to her accommodation provider to find ways to better manage and support June or to the DWP vulnerable client’s team to see how they were managing her benefits and financial support.

The referral for Together support was made in December 2021 but her assessment was not completed until the 25 February 2022.

There was no referral to IASC for a care and needs assessment under Section 9 or 11 of the Care Act 2014 to identify what support June needed for day-to-day living or how she was managing her finances. Indeed, this assessment was not considered when the safeguarding referral was made.

The lack of responses from agencies to important referrals made by the GP prompts reflective questions on how professionals making referrals can initiate direct contact with professionals in other agencies or can access escalation pathways within their service to seek support from managers to expedite responses and reconcile concerns they hold. There needs to be a clear process, widely communicated and understood by the Partnership agencies, which enables professionals to rigorously pursue and resolve serious professional concerns they are managing.

Joint working

Multi-agency working is vital to the health of an effective safeguarding system where the potential exists to make the whole greater than the sum of the parts. As noted in the TDSAP thematic review of self-neglect cases, its crucial to establish a shared multi agency strategy for self-neglect where each agency understands its contribution and where the response is coordinated by a lead professional. Collaboration, joint visits, and consultation are all hallmarks of effective joint working.

June’s case offers some evidence of good bi-lateral working but not of a full multi-agency approach. The ambulance service attendance on 6 April which resulted in a request for the GP to attend to June shows effective joint working in the context of June’s significant needs at that time.

There is evidence of joined up approaches between her GP and Liaison Psychiatry, her GP and the endoscopy team. Together in undertaking their assessment also recognised the valuable support that can be offered by other agencies to help manage the risks associated with her alcohol misuse.

However, there were some fundamental shortcomings which precluded more effective joint multi agency working. As covered in detail earlier in this report, these shortcomings are linked to the absence of a care and needs assessment as well as the absence of a multi-agency Section 42 response in terms of gathering information and undertaking a safeguarding enquiry. This was amplified by a lack of investigation on issues of self-neglect and IASC decisions being made on limited information. 

Joint working and shared expertise may also have been beneficial during the considerations of June’s mental capacity with wider opportunities explored including inherent jurisdiction, and a Section 11 Care Act 2014 assessment.

The absence of effective multi agency collaborative practice in response to June’s care and support needs was a major oversight in this case. Whilst there were individual service responses and interventions, there was no coordinated multi-agency action plan designed to address both the scale and urgency of June’s self-neglect. The need for a coordinated multi- agency safeguarding response was not recognised. Consequently, no agency was coordinating all elements of risk or had a holistic view of June’s care and support needs.

When the GPs safeguarding referral did not proceed to a Section 42 Care Act safeguarding enquiry, no multi agency meeting was considered to explore risk management strategies for June. The risks were perceived to be being managed via a mental health assessment between mental health services and her GP which in any event was not organised before June died.

TDSAP have developed a Multi-Agency Risk Management Meeting (MARMM) guide[13] to support the oversight of cases that sit outside of the statutory framework and requirements of the Care Act but for which a multi-agency approach may be beneficial. Any agency can initiate this process and take the initial lead for convening and chairing a meeting which will focus on sharing information with partners to establish and manage risks which don’t reach the threshold for a Section 42 Enquiry. This was raised at the learning event as another option to be considered by agencies to assist with the joint management and coordination of self-neglect cases.

DOMAIN C: Organisational features and systems influence

Features of organisations and the context in which organisations work can adversely affect practice. These features can range from external pressures, resource constraints to the internal systems and processes that organisations use. Such features are evident in June’s case.

Staffing and demand pressures

IASC acknowledge that at the time in scope of this review, duty managers working in the Safeguarding Hub in addition to triaging safeguarding referrals were also carrying a wider day to day workload which included:

  • Whole service safeguarding commitments and meetings
  • Supporting the management of their staff
  • Holding individual enquiries
  • Time pressures, managing duty responsibilities and the overlap with managerial tasks caused strain on the duty manager roles at this time.
  • The volume of referrals created pressures and meant that people were waiting longer on waiting lists before triage and assessment processes were undertaken. An interim risk matrix was also in use at the time.

Several pressures at Together were evident at the time of June’s referral to the service including challenges with the recruitment and retention of qualified staff as well as managing a higher demand for drug and alcohol services post Covid-19. The month gap between screening June’s referral and allocating the case to a recovery worker, in the context of these organisational pressures, was not seen by managers in the service as significant or indeed detrimental to June’s overall care.

DPT referenced staffing challenges in community mental health teams as well as working practices that were still adjusting to the pressures in the system from the Covid-19 response. Similarly, the Gastroenterology and Endoscopy team recognise that the Covid-19 restrictions delayed the endoscopy in July 2020 and that telephone assessments became the standard practice during Covid-19 with restrictions on visiting hospitals in place. But it’s not suggested these issues impacted on the quality of treatment offered by either service to June in the timeframe of this review.

Recording and agency systems

Adult Social Care

The IASC internal management review highlights several issues with the recording of information and use of different systems. Any decision making, or risk management interventions should be recorded within IASC on the ‘V5 safeguarding form’ as standard practice. However, in this case, reviews and updates were only recorded on an excel spreadsheet (used to record the waiting list of cases for triage) which was not connected with the Care First system (the IASC recording system). There was therefore no opportunity for social workers to view the case chronology or to examine case updates. Other recording omissions included:

  • There is no record on their systems that they informed the mental health team of the open safeguarding concern for June.
  • No records were made of discussions with mental health teams or her GP until after June passed away.
  • There is no recorded evidence that the risk management tool was considered when the safeguarding referral was triage.
  • No clear recording of the rationale to support the RAG rating and risk management approach adopted.

Conversely, IASC reflect that the checking of partners recording systems was detailed in terms of the DPT Care Notes and having access to the Care Notes recording system used by mental health teams was also seen as beneficial. This access enabled IASC to see the progress made with communicating, visiting, or engaging with June.  However, the review has established that IASC no longer have direct access to the electronic recording system used by DPT for reasons of confidentiality. Current practice requires IASC professionals to directly contact the relevant physician within DPT.

The review did highlight good social work practice with the way one team member recorded their observations and saved email communications on their systems.

Mental health teams

There was a note recorded on the screening form for SPA to notify the GP that any safeguarding concerns they may have needed to be acted upon without waiting for the assessment because joint assessments can take a longer time to arrange. It’s not clear from the notes if this was actioned. There was no record of a follow up or response recorded on the notes following the GPs contact on 6 April enquiring about the urgent referral for a mental health assessment made on 15 March 2022. DPT acknowledge that the recording oversights are ones of individual practice as well as systemic challenges with managing a high volume of case referrals.

Together

Held comprehensive records for their work with June which gave a detailed insight into their activity to support the completion of their comprehensive assessment. However, there were some shortcomings in terms of not recording the completion of certain activities including the Healthier Me assessment or the actions taken to address the large debt being held by June.

DOMAIN D: Governance

Safeguarding Adults

The TDSAP fulfils the function of a local Safeguarding Adults Board (SAB) for both the unitary authority of Torbay and the county of Devon. Local authorities have a statutory duty (Care Act 2014, section 43) to establish a SAB, with the Board’s statutory function being to help and protect adults in its area who have care and support needs, are experiencing or at risk of abuse and neglect (including self-neglect) and are unable, because of their care and support needs, to protect themselves. It must achieve this by co-ordinating and ensuring the effectiveness of what each of its members (partner agencies) does.

In addition to its statutory function as set out above, the Partnership has under Section 44 of the Care Act 2014 a power to carry out a review of any case that comes to its notice. In respect of certain cases, where specific grounds are met, the review becomes mandatory. It is relevant therefore to consider how the Partnership has met governance requirements in terms of carrying out this review.

The records show that IASC were not notified of June’s death until 21 April 2022, 10 days after her death. In June 2022 IASC raised a query with the GP on the cause of death and enquired on the appropriateness of a SAR referral. There is no record of a response to these enquiries.

In February 2023, June’s case was raised at a local GP forum and the question was asked if a SAR had been commissioned. Various approaches were then made to DPT and the Coroner’s office before it was established a SAR referral had not been made. Consequently, a SAR referral was submitted to the TDSAP from IASC. This was received in March 2023, 11 months after June has died.

It is not clear why the SAR referral was not made much earlier, but the lack of overall case coordination may be one explanatory factor. The fact that the case wasn’t referred should be an area of concern for the Partnership.

Following a TDSAP SAR Core Group meeting in May 2023 a decision was made to progress to a SAR. The lead reviewer was appointed in February 2024 and the first SAR panel meeting was held in March this year. There was therefore a considerable time delay between June’s death and the eventual SAR referral, the commissioning of the SAR review and publication of the independent learning.

To their credit, agencies, particularly IASC, have sought to maximise learning opportunities and embed changes arising from this and other self-neglect cases before the review was completed.

However, not only do the delays potentially impact on extracting timely learning from the circumstances of her death, but it is also likely to be a source of distress to her family as well as professionals, who by the time this review concludes will have waited for over two years for an understanding of how agencies worked in support of June. The coronial process has also been impacted by the delays in the completion of this review.

The TDSAP is aware of the risks in delays with SAR processes and are actively managing these risks through a risk register process with Board level oversight. The learning from this review suggests the need for continued regular quality assurance activity on its referral pathways from agencies, decision-making and governance relating to SARs to minimise delays in future reviews.

[4] Section 9 Care Act 2014-the local authority must carry out an assessment of anyone who appears to have care and support needs.

[5] Mental Health Act (1983) is the primary piece of legislation that covers the assessment, treatment and rights of people with a mental health disorder.

[6] Manthorpe, J; Harris, J; Burridge, S; Fuller, J; Martineau S; Ornelas, B; Tinelli, M and Cornes, M (July 2021) Social Work Practice with Adults under the Rising Second Wave of COVID-19 in England: Frontline Experiences and the use of Professional Judgement. BJSW Vol 51 no 5 pps 1879-1896.

[7] Self- Neglect Thematic Safeguarding Adult Review (SAR), March 2022, Spreadbury K. (Reference commissioned to learn from the circumstances surrounding the deaths of 6 people related to aspects of self-neglect in Hampshire between March 2020 and January 2021March 2022. The analysis from their review, published in March 2022)

[8] Braye, S., Orr, D. and Preston-Shoot, M. (2017), “Autonomy and protection in self-neglect work: the ethical complexity of decision-making”, Ethics and Social Welfare, Vol. 11 No. 4, pp. 320-35 3 6 Thacker, H; Anka, A; Penhale, B (2019) Could curiosity save lives? An exploration into the value of employing professional curiosity and partnership work in safeguarding adults under the Care Act 2014 The Journal of Adult Protection Vol. 21 No. 5 2019, pp. 252-267)

[9] 39 Essex Chambers carrying out and recording capacity assessments, March 2023, A Keene KC (Hon) et al.

[10] Preston-Shoot, M; Braye, S; Preston, O; Allen, K; Spreadbury, K (2020) Analysis of Safeguarding Adult Reviews April 2017 –March 2019. Local Government Association https://www.local.gov.uk/sites/default/files/doc:ments/National%20SAR%20Analysis%20Final%20Report%20WEB.pdf

[11] Preston-Shoot, M., 2017. On self-neglect and safeguarding adult reviews: diminishing returns or adding value? The Journal of Adult Protection, 19(2), pp. 53-66.

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

[13] TDSAP Multi Agency Risk Management Meeting (MARMM), overarching principles and guidance, V5, March 2024

10. Agency learning and practice changes

It’s evident to the reviewer that following June’s death there was a genuine desire from the agencies to constructively learn from her case and address shortcomings in practice. In IASC, a staff working group was established to consider practice and policy themes, systems and guidance in the period after June’s death.

A Serious Incident Review (SIR) was also commissioned by IASC at the time of the SAR referral in April 2023. This review was led by a senior manager in IASC who had concerns on the way the original safeguarding referral in March 2022 was managed, This review was focused on understanding how decision making was informed, how decisions aligned to statutory guidance and local guidance as well as what could have been done differently and establishing how learning could be taken forward as part of a ‘Rapid Improvement Approach’ (an approach designed to enhance processes, systems, and skills of practitioners).

Because of all this work, IASC embraced a comprehensive number of actions to improve the effectiveness and management of safeguarding referrals including:

  • Establishing a new waiting list for referrals which explicitly records why a case is a risk and who is leading on the review of the RAG rating.
  • A more robust and sensitive approach to the timeliness of triaging and re-triaging referrals.
  • Referrals which evidence a mental health condition as the primary need, are now treated with a consideration for how the condition is impacting on the individuals’ circumstances, the associated risks, safety and protective factors.
  • Developing a Safeguarding Risk Matrix following a thematic review of safeguarding best practice and risk matrix information.
  • Providing greater clarity of managers roles and professional boundaries enabling a greater focus on daily tasks.

For the police, the lack of information sharing via the ViST process was found to be a deviation from expected organisational practice and guidance by an individual and was not an organisational failing. This was brought to the attention of a supervisory officer and the matter addressed as an individual training need.

Together managers reflect a confidence that comprehensive assessments are now routinely undertaken in person. People on a waiting list for an assessment are contacted by phone to more readily identify risks or if the risks are escalating. The process for closing cases has also been improved and the 3 day a week opening of their Recovery Café offers a safe space for patients to visit or engage with workers.

A follow up meeting has also been held between the Named GP for Safeguarding Adults in the ICB and June’s GP where the support processes for the escalation of cases by GPs to the ICB were explored. The ICB are also developing a Mental Capacity Act tool to support Devon GPs with Mental Capacity Act (2005) assessments, the signposting of guidance and recording of decisions.

The Partnership have shown a strong commitment to improving responses to self-neglect, publishing guidance on self-neglect and hoarding alongside its more general safeguarding procedures and other guidance on aspects of safeguarding practice. Further, it commissioned and published the thematic review of 6 self-neglect cases, utilising recognised national experts in the field of adult safeguarding who identified 18 recommendations.

11. Review recommendations

Assurance, monitoringand accountability

TDSAP commissioned thematic review of self-neglect cases published in February 2023 identified 18 recommendations for the Partnership or individual agencies to address. A number of these recommendations have relevance to June’s case.

Recommendation 1: The TDSAP Board should ensure the recommendations and learning from June’s SAR feature as part of the monitoring, auditing and assurance activity developed in response to the 18 recommendations in the thematic review of self -neglect cases published in February 2023.

Recommendation 2: The monitoring, auditing and assurance framework adopted by TDSAP for self-neglect SAR recommendations should be appended to this report and used to inform HM Coroner at June’s inquest.

Understanding current safeguarding practices and the legal framework for self-neglect cases

Agencies have adopted fundamental changes to working practices since June died, particularly IASC’s management of safeguarding referrals. There is benefit in ensuring all professionals managing self-neglect safeguarding cases are aware of current single agency practices and better understand how the multi-agency safeguarding system works in support of those who self-neglect.

Understanding the legal framework for safeguarding and self-neglect is also relevant and includes the safeguarding referral process, application of the Mental Capacity Act, Mental health assessments and the Section 9 and 11 Care Act 2014 provisions.

Recommendation 3: The TDSAP should consider how best to ensure safeguarding professionals are regularly kept apprised and develop a shared understanding of safeguarding processes for self-neglect. The development of a self-neglect good practice guide or compendium may help in this regard.

Recommendation 4: The TDSAP should seek assurance on how agencies develop enhanced professional confidence in their teams with the application of legal considerations for self-neglect cases, including:

  • The Mental Capacity Act (2005)
  • Article 2 ECHR right to life
  • Inherent jurisdiction
  • Section 9 and 11 Care Act 2014 assessments.

Multi-agency working

Multi-agency working was not a strong feature of this case. The absence of a risk management approach, care and support needs assessment or safeguarding enquiry all contributed to this. There were occasions in the months prior to June’s death when considerable benefits could have been secured with agencies meeting to coordinate the approach to June’s care. Such meetings would have complemented and supported the work of her GP.

Recommendation 5: The TDSAP should seek assurance, through quality assurance activity, that multi-agency working and escalation pathways for cases of self-neglect are being applied in practice.

Recommendation 6:  The TDSAP in discussion with IASC should establish the most effective way to engage with the GP practice in this case to set out the changes to the multi-agency management of self-neglect safeguarding referrals and the associated practice developments since June’s death.

Mental capacity

No professional underestimates the complexity and multi- faceted challenges of assessing an adult’s capacity especially so when an adult is self-neglecting and determined to manage their own situation. The availability of expertise and guidance for professionals is essential to support the best outcomes.

In this case, and in the context of developments in this area since June died, there is scope to improve the application of the Mental Capacity Act (2005). This is particularly relevant with identifying the process of assessment and how this process and decisions are recorded.

As reflected in recommendation 4 above, wider considerations of a Section 9 or 11 Care Act (2014) assessments, inherent jurisdiction, meeting the requirement of Article 2 ECHR (right to life), are also germane to the learning from June’s case. The legal insight, case law, precedent and practice understanding of the Mental Capacity Act and related issues have evolved significantly since June died.

Recommendation 7: The TDSAP should establish how agencies monitor the use of the Mental Capacity Act 2005 by staff and supervisors, including how agencies evaluate Mental Capacity Act training and embed learning from cases, such as June’s.

Recommendation 8: The pathways for practitioners to access Mental Capacity Act (2005) advice, guidance, and expertise from within their own service and across the partnership should be widely communicated and be readily available to practitioners and managers.

Recommendation 9: The TDSAP should seek assurance on how the Integrated Care Board will formalise the documentation and robustness of Mental Capacity Act (2005) assessments for GPs including (i) the process for assessing whether a person has mental capacity and (ii) the recording of the conclusion reached. This should be informed by the principles of accountability and transparency.

Mental health assessments

The GP referral for June’s mental health assessment was not responded to despite the urgency of June’s condition. The GPs follow up contact was not responded to by mental health services.

The review highlighted confusion and frustration on how to access mental health services. In addition, the provisions of the Mental Health Act (1983) and treatment in a place of safety and differences between this Act and a mental health assessment were not widely known and should be clarified.

Recommendation 10: The Devon Partnership Trust should also ensure that TDSAP agencies are informed about the pathways and service standards for the provision of mental health assessments and Mental Health Act (1983) assessments and how they can be applied to cases of self-neglect. Pathways for accessing mental health support in a crisis are published on the Devon Partnership Trust website and on the TDSAP website. All agencies should ensure their staff know where to find this information.  I need help now | DPT

Escalation process for professional concerns

It’s evident in this case that the referral pathways for the GP to escalate professional concerns or frustrations within their own service or with other partners was unclear and were not ultimately pursued. Escalation to other managers, for example, in the Integrated Care Board or Together service, may have led to a focused multi-agency response that the urgency of June’s condition required.

Recommendation 11: The TDSAP needs to clarify with agencies how and to whom professionals can escalate professional concerns including disagreements or conflicts between partners for adult safeguarding issues. Professionals should have the ability to communicate directly with managers in other agencies to address concerns.

Engagement strategies for people who self-neglect

A feature of this case was June’s reluctance to attend meetings or keep appointments, designed to ensure she had appropriate health care and support. Very few agencies had visibility of her deteriorating condition and when they did it was at times of crisis a few days before she died. Professionals who contributed to the review acknowledged that there is a resource implication for properly engaging with and supporting the complex needs of individuals who may be self-neglecting. Whilst the benefits of home visits are valued, staffing constraints within the system can challenge opportunities to do so.

Recommendation 12: The TDSAP should explore with practitioners, creative ways to engage with adults who are self-neglecting and maximise opportunities to understand the home conditions and visibility of the adult self-neglecting.

12. Review Learning Points

Accommodation providers

Accommodation providers are key services often with direct agency and relationships with their tenants and can use measures under the Housing Act 2004 to contribute to their care, support and safeguarding needs. Safeguarding professionals should seek to establish the named identity of accommodation providers and use the providers statutory and wider influence to safeguard adults at risk of self-neglect.

Learning point 1: The value and contribution of community stakeholders, such as accommodation providers, should always be established by agencies delivering safeguarding services and managing self-neglect cases.

Crisis and risk management

DPT on behalf of partners have previously led on developing risk management and crisis management advice including a flow chart for crisis advice and a policy for risk management meetings. Neither of these appeared to be widely used or indeed known by agencies.

Learning point 2: The flow chart for crisis advice developed by the DPT and promulgated through the TDSAP Learning and Improvement subgroup should be relaunched and widely distributed with agencies. The guidance on the TDSAP Multi Agency Risk Management Meetings is being updated and should be redistributed and briefed to partner agencies when finalised.

Risk assessments

Fire risks and self-neglect are common factors that should not be overlooked from a safety perspective, although these risks don’t appear to have been considered in this case. June’s self-neglect and hoarding behaviour has not been established but it’s clear from what has been presented that fire was another risk factor for June that needed consideration.

Learning point 3: In cases of adults self-neglecting, professionals attending a person’s home should consider fire safety checks and home safety risk assessments.

Value of case studies as a learning tool

Learning point 4: Attendees at the learning event highlighted the value and benefits of using June’s experiences as a learning and development case study for practitioners managing adult self-neglect cases.

Delays in the SAR process

Any delays in the SAR process should be understood and promptly communicated to family members or their advocates and other relevant stakeholders (Coroners).

Learning point 5: The TDSAP chair should continue to maintain an oversight through the risk register on the timeliness of SAR referrals and the decision making leading to the commencement and publication of SARs. Communication with families and stakeholders on the progress and potential delays with these statutory processes should be regularly reviewed and shared.

13. Additional consideration in response to this SAR – Reimbursement of general practitioners (GPs) supporting SAR processes

It became evident during the review that GPs are not directly reimbursed for their time contributions to a SAR process. In June’s case the lead reviewer had a one-to-one meeting with her GP and exchanged emails. The GP was present for the first part of the learning review and has also written letters to the coroner in respect of this case. It is acknowledged that it can be challenging for GPs to contribute to the SAR process with limited resources. When it is appropriate to do so, they have a statutory and professional duty to engage and make their valuable contributions to local safeguarding reviews. 

GPs are key professionals within the safeguarding system that need to be enabled to fully contribute to all aspects of safeguarding activity, including review processes. It is noted that the Devon ICB Safeguarding Primary Care Team are currently undertaking scoping work for direct GP payments for safeguarding work in line with national guidance on this issue.

The TDSAP Board Chair is encouraged to explore through regional and national networks the experience of other Safeguarding Adults Boards with reimbursement issues of GPs for their time commitments to SAR processes. Consideration should be given to the interim local arrangements being developed by the ICB until the national position is clarified.

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