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