1. Background to the Safeguarding Adults Review (SAR)
1.1 A Safeguarding Adults Board (SAB) is required to undertake a Safeguarding Adults Review where.
· An adult with care and support needs has died and the SAB knows or suspects that the death resulted from abuse or neglect.
· There is reasonable cause for concern about how the SAB, its members or others worked together to safeguard the adult.
1.2 Rachel was found deceased at her home address on 30th October 2022. She was 51 years old. Devon and Cornwall police attended having received a call from her daughter with concerns for Rachel’s welfare. Officers reported that they believed Rachel may have passed away some time before she was found, and her exact time of death is currently unknown. Her death will be the subject of a Coroner’s Inquest which will confirm the time and cause of death. A pre-inquest review meeting is being held on 23rd April 2024.
1.3 A referral for a SAR was made by Devon and Cornwall Police, citing concern regarding how partner agencies had worked together to safeguard Rachel. They highlighted the number of organisations Rachel had been known to and her physical and mental health needs. Their concern related to how agencies had worked together to prevent the self-neglect they witnessed when attending her home on 30th October 2022.
1.4 During the 12 months prior to her death Rachel had had 8 separate attendances at the Royal Devon and Exeter Hospital and was admitted on 6 of these occasions. On 2 other occasions she attended having intended to harm herself by taking her prescribed medication incorrectly and was discharged the same day. On an earlier admission on 22nd September 2021 several agencies had identified self-neglect as a significant factor.
1.5 On the basis of this information it was determined that a Safeguarding Adults Review should be commissioned because Rachel had been a person in need of care and support, self-neglect was considered to have been a factor in her death and it was suspected that partner agencies could have worked together more effectively to safeguard her.
2. Terms of Reference
2.1 The Terms of Reference for the SAR are to:
1. Review and evaluate the information submitted by the agencies working with Rachel in the 12 months leading up to her death to inform any new learning.
2. To consider what was known by agencies and when about Rachel’s history and home circumstances whilst working with her.
3. To engage with family members/friends to better understand their involvement in Rachel’s life.
4. To consider how issues of self-neglect were considered, approached, and responded to.
5. To assess the quality of multi-disciplinary working and how information was shared.
6. To cross reference any learning and recommendations from the thematic review around self-neglect commissioned by Torbay and Devon Safeguarding Adults Partnership and published on 15th February 2023 and to highlight any additional learning.
7. To identify a specific set of learning points for the panel to consider.
2.2 Methodology
In accordance with the Care Act 2014 and accompanying statutory guidance, SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so lessons can be learned from the case and applied to prevent similar harm occurring again in the future.
The review will consider a focused methodology. Agencies involved in the SAR will be asked to fully participate at SAR panels and to provide information to the lead reviewer. The review will highlight key learning themes for partner agencies to embed into operational practice.
The Lead Reviewer has analysed the Individual Management Reviews submitted by agencies ensuring information is cross referenced to provide a consistent analysis of the information provided. There has been a particular focus upon Rachel’s admissions to hospital during 2022 as key events as this is when agencies were seen to share information and engage with each other about how best to support her.
Family members have been contacted to determine if they wish to participate in the review and provide any relevant information.
3. Agencies involved with Rachel
3.1 The following agencies contributed Individual Management Reviews.
· Devon Partnership Trust (DPT). Rachel was known to the mental health trust from 2011. In the 12 months that the review covers, she was seen extensively by the Psychiatric Liaison Service when admitted to Royal Devon and Exeter Hospital throughout 2021/2. This team collated an extensive and strong social history for Rachel which was good practice and shared this with partner agencies. Rachel was known to the Home Treatment Team and the Community Mental Health team.
· Devon and Cornwall Police- responded to a number of calls from Rachel, her daughter and other organisations and individuals.
· Rolle GP Practice- provided primary healthcare services.
· Devon and Somerset Fire and Rescue Service- received several referral requests for home safety visits in relation to fire safety at Rachel’s home.
· Devon County Council, Integrated Adult Social Care (ASC)- received a number of safeguarding concerns about Rachel and subsequent case allocation. They were also involved in her discharge planning arrangements.
· Royal Devon University Healthcare NHS Foundation Trust- Rachel attended hospital 8 times and was admitted to Royal Devon and Exeter Hospital on 6 of those occasions.
· East Devon District Council (EDDC) – Housing- dealt with an application for housing following an S21 notice and eviction proceedings.
· South West Ambulance Service NHS Foundation Trust – Responded to 11 calls in the 12 months period prior to her death.
4. Family involvement
4.1 Rachel has two children, a son, and a daughter. Her daughter Kay was in regular contact with her Mum on an ongoing basis although at various points during the 12 month this SAR reviews, professionals have recorded Rachel’s request not to share information with her daughter. Kay describes a situation where Rachel made it hard for people to help her as she was worried about people talking about her personal circumstance and would want others to think everything was fine when it clearly was not. It was hard for Kay to see her Mum deteriorating, but she visited on an almost daily basis when she was in hospital and stayed in regular phone contact. Kay has described how Rachel could be reactive to situations and that she believes that Rachel was unaware of her diagnosis of emotionally unstable personality disorder. As a result, family members were unable to support in an appropriate way, but knowing this now gives perspective to some of the ways that Rachel reacted to situations and other people. Despite these challenges Kay has been an invaluable source of information in agencies understanding Rachel’s background and history and Kay also raised concerns about her welfare with statutory agencies who were then able to intervene. It was Kay that alerted the police prior to Rachel being found deceased at home. If she had not done so further time would have elapsed.
Rachel’s son has indicated that he does not want to be consulted directly as part of this review.
Kay identified that Rachel’s twin sister and also her close friend Jeanine would want the opportunity to contribute to the review. Both have been contacted and Jeanine and her daughter Charlotte have provided information about Rachel’s life which has been included in the report.
4.2 Kay has had contact with Adult Social Care, Devon Partnership Trust, and The Royal Devon University Healthcare NHS Foundation Trust as part of internal single agency reviews that have already been completed prior to this Safeguarding Adults Review taking place.
5. Rachel
5.1 Rachel was born in Hastings and grew up in Bromley. She was married in 1997 and divorced some years later. She met Kay’s stepfather when Kay was 3 years old. He has always been a support for Kay and her brother. The family moved down to Devon when Kay was a young child. Her mother missed her wider family but loved Devon.
5.2 Rachel was described as ‘vibrant and loved working’ in her younger years. She worked at a local school, and she had a ‘soft spot’ for the schoolchildren. She was also described as being ‘really caring and funny’ and Kay’s friends ‘loved her’. She would show her love and affection for Kay and her brother through caring actions, such as making a favourite meal. She was fun as a parent.
5.3 Jeanine has described Rachel as a lifelong friend who she first met when she was 5 years old, When Rachel moved to Devon, they stayed in contact initially regularly and then more sporadically with telephone contact becoming very regular again in the 2 years before Rachel’s death. Jeanine was aware that Rachel had become unwell and described difficult conversations over the telephone with Rachel “whispering” so that neighbours could not hear. On reflection Jeanine wonders if this was due to a deterioration in Rachel’s mental health and/or an increase in her use of alcohol. Jeanine was aware that Rachel’s alcohol consumption had gradually increased over the years, but this was denied. Jeanine was not always sure if Rachel was accurately describing her home circumstances and when she offered to visit in August 2022 to offer Rachel some support this was accepted and then very quickly declined as Rachel described feeling embarrassed about her circumstances.
When the school she worked at closed, Rachel started working in social care and worked with various care agencies, supporting people in their own homes. Without access to a reliable car, she then started working in care home settings either in the kitchen or providing hands on care to vulnerable people. Various professionals have reported that in their conversations with Rachel she was proud of her job and enjoyed the work.
Rachel did not work for about 3 years when her mother contracted cancer, which had a major impact on Rachel. Jeanine confirmed that Rachel had been very close to her mother and would speak to her on a daily basis on the telephone. She felt her loss greatly.
5.4 Rachel had a number of health conditions including atrial fibrillation, a heart condition that causes an irregular and often abnormally fast heart rate, she had suffered with back pain, a hernia and had been diagnosed with anxiety, depression, and an emotionally unstable personality disorder at the time of her death. Her alcohol intake increased significantly following her divorce in 2010. This affected her ability to continue working and she eventually lost her job shortly before her death. Rachel had been living in private rented accommodation and was due to be evicted from her home on 1st November 2022, due to the poor condition of the property.
5.5 The Equality Act 2010 confirms that a mental health need which has a substantial, adverse, and long-term effect on your ability to carry out normal day to day activities is a disability and therefore a protected characteristic under the legislation. Rachel’s long term mental health needs means that she met this criteria and evidence submitted to the Lead Reviewer has not demonstrated that partner agencies recognised this or made “reasonable adjustments” in recognition of this.
6. Overview of partner agencies involvement with Rachel in the 12 months prior to her death
6.1 Rachel was known to all the agencies who have taken part in this review with varying levels of contact. The majority of interaction occurred around her hospital admissions, so I have focused on these as a way of providing a more focused overview. The admissions highlight partner agencies involvement and onward referrals made.
Rachel was seen at the Royal Devon and Exeter Hospital on the following dates:
22nd September 2021- admitted by ambulance due to wounds to her lower legs. The ambulance crew made a safeguarding referral referencing self-neglect due to the poor state of the property. Diagnosis of bilateral cellulitis of lower legs and delirium due to infection made. Rachel was placed under a deprivation of liberty safeguard at the start of her hospital stay which was later removed.
13th January 2022- admitted by ambulance who were called by Rachel’s daughter Kay who had not seen or been able to contact Rachel for some time. The ambulance crew found her covered in faeces with pressure areas and the property in a state of severe neglect. Empty vodka bottles also seen. Rachel was seen by the tissue viability team due to the level of skin damage she was experiencing. Diagnoses of infected cellulitis in legs, alcohol issues and self-neglect were recorded. Rachel tested positive for C. Diff, a type of bowel infection. A diagnosis of emotionally unstable personality disorder was referenced as was anxiety and depression. It was believed that the infection had contributed to the deterioration in Rachel’s mental health and ability to care for herself. A deep clean of Rachel’s home took place prior to hospital discharge.
6th April 2022- Rachel was admitted by ambulance due to atrial fibrillation and deteriorating mental health. The ambulance crew made a safeguarding referral to Adult Social Care in relation to self-neglect at home. Kay expressed her concerns regarding the risks at home for Rachel clearly to ward staff. A full social history was taken by ward staff which gave a background of alcohol misuse, mental health issues and severe self-neglect for herself and her home. Initially Rachel was agitated on the ward and was treated for an infection. It was believed she was suffering from delirium. Rachel articulated to staff that she was not managing at home and needed support to clean her property. She also stated that she was a “binge drinker” occasionally and she was treated with chlordiazepoxide, for symptoms of alcohol withdrawal on admission. A further deep clean of her property was arranged prior to discharge and she agreed to have support from the re-ablement home care service on discharge.
7th May 2022- Rachel was admitted to hospital by ambulance due to palpitations and hallucinations. Rachel had not been taking her medication at home. She had a suspected chest infection causing atrial fibrillation and was also treated for alcohol misuse. Kay advised staff of the cycle of discharge and re-admission over the past 6 months. Concerns were also noted about Rachel’s level of depression. She was later discharged with a referral to the Mental Health Home Treatment Team.
5th June 2022- Rachel was admitted by ambulance following concerns raised by Kay. Rachel was found to be self-neglecting, using alcohol and with deteriorating pressure ulcers. Rachel reported not sleeping for the last 5 days and had not been taking her medication. The crew found tablets, food, and cigarette ends over the floor. They had to access the property by climbing through a window. Rachel was treated for cellulitis, C. Diff, pressure areas, atrial fibrillation, and delirium. Rachel was described as paranoid and delirious at the start of her hospital stay. She also attempted to take an overdose of her medication whilst on the ward telling staff that it had been her intention to end her life. Rachel was assessed to have fluctuating mental capacity around discharge arrangements by the Psychiatric Liaison Team on this admission. They felt that her personality disorder and use of alcohol contributed to the self-neglect. They noted as did the occupational therapist that there was a pattern of Rachel agreeing to support whilst in hospital but this not being accepted once she returned home. The Psychiatric Liaison Team completed a capacity assessment considering executive capacity towards the end of this admission and concluded that Rachel had the capacity to make informed decisions about her discharge and care and support needs at home.
12th July 2022- Rachel was admitted by ambulance with a decline in her mental health and possible atrial fibrillation due to Rachel not taking her medication. Rachel advised that she had also taken an overdose of paracetamol and other prescribed medication. Kay again expressed her concern about the care Rachel was receiving and advised of an eviction notice. Expressing paranoid ideas about neighbours Rachel locked herself in the bathroom on the ward. Rachel was refusing treatment for acute vitamin deficiency. The ward was advised to consider a deprivation of liberty safeguard if Rachel tried to leave the ward. Later on, Rachel accepted that she was self-neglecting and felt this was due to the atrial fibrillation that limited her mobility and continued lack of sleep. The ward had contact with East Devon District Council Housing and ensured that a referral to the Home Treatment Team was made, with a visit commencing on the day after discharge 27th July 2022. Rachel agreed to accept help on discharge as she had done previously.
5th August 2022- Rachel was admitted with an intentional overdose of medication, she stated that she had intended to end her life as she had lost her job and was about to loose her home. Rachel had called the ambulance. She was also experiencing atrial fibrillation. Rachel stated that she was dealing with the issues she had at home. She was discharged the same day with support from the Home Treatment team who were to complete a joint visit with the Community Mental Health Team.
9th August 2022- Rachel was taken to hospital having called an ambulance after a further intentional overdose of prescribed medication. Rachel stated that this is because nobody was listening to her about the persecution she was suffering from her neighbours. Rachel then expressed embarrassment about what she had done, and the Psychiatric Liaison Team felt that she did not present with an acutely altered mental state. She was discharged the same day with a known appointment with the Community Mental Health Team on 20th August 2022.
15th August 2022- Rachel was admitted by ambulance due to increasing anxiety and palpitations. Rachel had not taken her medication. Psychiatric Liaison noted that there was no evidence of suicidal ideation butt they were concerned that Rachel remained at high risk of self-neglect with subsequent risk of death by misadventure. She was discharged the following day back into the care of the Community Mental Health Team.
In addition to Rachel’s unplanned hospital admissions the following information has been provided:
6.2 Primary care involvement:
Rachel had been registered with her GP surgery for many years and Dr Wilcox reports having known Rachel for 15 years. During 2021/22 Rachel would contact the surgery when she needed health support both for her physical and mental health concerns. Rachel would be offered either a telephone appointment or a face-to-face appointment with one of the GPs. She often declined face to face opportunities and preferred to discuss her health concerns on the telephone. GPs did attempt to follow up her hospital admissions and, on some occasions, she would answer the phone or respond to messages. At other times there was no response. Several onward referrals for weight management, pain control and mental health support were closed in 2021 as Rachel did not respond to appointment letters or missed appointments. However, on at least one occasion this was because she was already in hospital, and it is noted that the departments receiving the referral from the GP surgery did not check back with them to understand Rachel’s current circumstances before closing the request for support. Dr Wilcox undertook an unannounced home visit to Rachel in July 2022 which was good practice but there was no reply. He also wrote to both Adult Social Care and East Devon District Council, about her housing situation in September 2022. He expressed his concern for Rachel’s safety and well-being on a number of occasions to partner agencies.
6.3 Devon Partnership Trust involvement (DPT)
Rachel was first referred to Devon Partnership Trust in 2011.In the intervening years she had multiple referrals in relation to her use of alcohol and concerns about her mental health. Most of their contact between October 2021 and October 2022 was when Rachel was admitted to hospital as outlined above. She was seen on 9 occasions by the Psychiatric Liaison Service between 23rd September 2021 and 16th August 2022 whilst she was an inpatient in the Royal Devon and Exeter Hospital. The team made a safeguarding referral to Adult Social Care on 15th July 2022 and on all admissions noted and expressed concern about risk of ongoing and deteriorating self-neglect. Concerns about these risks were logged with Adult Social Care who had received the safeguarding concern. Rachel was referred to the Home Treatment Team following the July 2022 hospital discharge and they planned to visit the next day on 27th July. Daily calls were made between 27th July and 3rd August 2022, but the team were unable to get see Rachel as she reported having diarrhoea and vomiting. The Community Mental Health Team became involved on 3rd August 2022, but Rachel missed several appointments including an outpatient appointment with the Consultant Psychiatrist on 23rd August 2022. Her recovery Co-ordinator completed an unannounced home visit on 14th September 2022 as she had been unable to see Rachel since becoming involved on 3rd August. Rachel was not at home. Shortly afterwards following a conversation in supervision the team closed their involvement with Rachel.
6.4 Adult Social Care involvement (ASC)
7th May 2021- Rachel was first referred to Adult Social Care. This request followed an overdose of her prescribed medication and a request for minor equipment to support her at home. Contact with Rachel identified several areas she needed support with which were not followed up and Rachel declined the support offered.
22nd September 2021- Rachel’s landlord raised a concern for her welfare, this was quickly followed by a referral from the ambulance service advising of issues of self-neglect. These were not recognised as safeguarding issues and therefore not progressed as such. There was also confusion as to the level of involvement from DPT and which organisation should lead on the issues raised.
In January & April 2022- Further safeguarding referrals were made to ASC but were not progressed to an enquiry as Rachel agreed to support on hospital discharge and seemed to be engaging with services and so social care staff felt it was disproportionate to continue with an enquiry.
The reablement home care service, which provides short term, focused support with a view to supporting someone to maximise their independence was asked to support Rachel on discharge from hospital and visited on 22nd April 2022, Rachel quickly ceased the visits saying she no longer needed them. This decline of services previously agreed was accepted and not referred back to the social care team.
13th June 2022 a further safeguarding concern was received from the ambulance service who had conveyed Rachel to hospital. The reason for the concern was self-neglect and on speaking to Rachel she identified the safeguarding risk as her neighbour’s behaviour. This was accepted by the Social Worker along with Rachel’s assurances that her property was being deep cleaned. Rachel’s daughter Kay contacted social care several times that same week and again in the next 2 weeks to advise of the level of self-neglect her Mum was experiencing and to advise that she had received an eviction notice from her landlord. She highlighted the repeated pattern of hospital admissions and deterioration when returning home and was clearly very concerned about Rachel’s welfare. There continued to be confusion about whether ASC or mental health services should take the lead on the work required to support Rachel and then the decision was taken that social care would complete a safeguarding enquiry in relation to self-neglect, but only once Rachel had been discharged from hospital. This decision was maintained and a request to co-ordinate an MDT meeting for discharge was declined by the Team Manager. Information from DPT and family continued to be shared with ASC during Rachel’s admission including an additional safeguarding concern in relation to self-neglect.
27th July 2022 a comprehensive summary from the hospital’s safeguarding lead was sent on discharge highlighting the complexities of Rachel’s situation and at this point the safeguarding enquiry was instigated, and contact made with East Devon District Council in relation to Rachel’s pending eviction on 6th August 2022.
Throughout August 2022 the Social Worker attempted to contact Rachel and completed an unannounced visit on 2nd August. A planned visit was unsuccessful on 10th August as Rachel had been taken to hospital the previous day. There was ongoing discussion with housing colleagues until Rachel was seen by the Social Worker at home on 23rd August 2022. On this occasion Rachel claimed to be unwell and so spoke to the Social Worker on the doorstep. The outcome of the conversation was that a Care Act assessment was required which would be commenced in the next few days during a further visit. This did not take place and Rachel continued to report having diarrhoea and decline home visits.
27th September 2022 The Social Worker finally gained access to Rachel’s home following a conversation with the Environmental Health Department. Rachel was reluctant to let the Social Worker see beyond the lounge which was reported as being very cluttered with empty bottles, food containers and rubbish and an unpleasant smell. Rachel declined the planned assessment and advised that she was feeling better and would deal with the clean the property needed and talk to housing about a move. This was accepted by the Social Worker.
28th September 2022 A further visit was completed, and Rachel talked in the hallway. Again, actions previously uncompleted were left with Rachel to pursue at her request.
On 29th September the GP alerted ASC to the fact that DPT had closed their involvement with Rachel as she had not taken up the offer of support and that he believed she was at “significant risk of death by either neglect, accident, overdose or from her physical problems”. The response suggested that on the previous day’s visit Rachel was more positive and she was going to resolve her home circumstances. The Social Worker believed Rachel had the capacity to make decisions about her care and support needs and would accept help when she was ready to do so. She was leaving the team in the next few days.
On 30th September 2022- ASC received a report from the police following a welfare visit to Rachel. It provided a detailed description of the severe self-neglect within her property and their concern for her welfare. This was not responded to and on 5th October a decision was made to cease the safeguarding enquiry and close Rachel’s involvement with the team. The rationale for doing so was that Rachel recognised her self-neglect and was now feeling able to deal with it. There was reference to Rachel’s belief that she was being threatened by her neighbour and this had been reported to the police and a possible move was being planned so no further help from social care was required. Risks identified were reported as mitigated because of the actions Rachel stated she would be taking.
In October further concerns were received from Housing and a suggestion that a thorough mental capacity assessment was required as Rachel continued to decline support although her situation and health were deteriorating
On 27th October- this led to a safeguarding concern being raised with a very detailed account of the risks to Rachel outlined by the housing officer. The concern was to progress to an enquiry, and it was agreed that an urgent home visit was required. This was not actioned. When contact was attempted on 3rd November 2022 sadly Rachel had already passed away.
6.5 Police involvement.
Rachel was seen by Devon and Cornwall police on 10 separate occasions from 4th January 2021 until 30th October 2022.They received 3 other calls that did not require their attendance, 2 from the ambulance service and 1 from a neighbour.
4th January 2021- Rachel rang the police, reporting that people were in her home. Officers attended and there was no sign of anyone else having been at the property. A vulnerability identification screening tool (ViST) was completed graded at medium risk. A ViST is submitted whenever a police officer identifies a person with care and support needs who is at risk of abuse or exploitation including self-neglect.
On 26th January 2021- The ambulance service reported having attended the property.
On 26th April 2021- The ambulance service reported having attended the property.
18th June 2021- Rachel rang the police to report “strange noises” from the local pub. Officers attended but there was no sign of any break in.
6th April 2022- Rachel rang the police reporting a third party trying to gain access to her home. Police attended and found nothing to report. Rachel declined a ViST being completed and shared with other agencies.
10th May 2022- Rachel’s manager at work called the police. She had contacted work colleagues to say she could no longer cope, and nobody could get in contact with her. Neighbours also reported post piling up inside the property. Officers attended but Rachel was in hospital receiving treatment.
4th June 2022- Kay called the police with concerns for Rachel’s welfare as she was unable to contact her after a worrying phone call. Police suggested Kay go to Rachel’s home and ring the ambulance service if required.
12th July 2022- Rachel’s neighbour called the police concerned for her mental health. Police did not attend but the ambulance service were called.
4th August 2022- the ambulance service alerted the police as Kay had phoned them saying that Rachel was planning to take an overdose of her medication. Simultaneously, a work colleague phoned the police to advise Rachel had now taken an overdose. Officers attended and reported that this seemed to be as a result of a disciplinary meeting at work. They completed a ViST- graded as medium risk because of the very poor state of Rachel’s home.
5th August 2022- Kay rang the police thinking Rachel was missing from hospital. She was reported as a high-risk missing person but was later found at home having been discharged from hospital already.
6th August 2022- Rachel called the police to report an issue with her neighbour. No crime was established. Kay rang later the same day to report a post on Facebook that Rachel had posted stating she was going to self-harm. Officers attended and Rachel denied any intent to harm herself. Police discussed the situation with the mental health street triage team.
9th August 2022- Rachel rang the police to advise she had taken an intentional overdose; the police alerted the ambulance service.
15th August 2022- Rachel’s landlord rang the police with a concern for welfare as the neighbours had not seen her for some time. Officers attended but Rachel did not appear to need their support.
16th August 2022- Rachel rang the police at 4:30am reporting a break in at her home. Officers attended but there was no sign of a break in or anybody else there. Due to evidence of self-neglect, they completed a ViST- graded medium risk and also referred to the fire service for a home safety check as the property is in a very poor state.
23rd September 2022- Rachel called the police stating that she was being threatened by a local female. Police attended and recognised a mental health crisis. Rachel’s home was described as “filthy”, and officers reported being bitten by flies and Rachel also being affected by flies but being unaware. A ViST was completed and graded at medium risk and shared with partner agencies.
30th October 2022- Kay phoned the police as she hadn’t been able to establish contact with her Mum and was very concerned. Officers attended and Rachel was found dead at home.
6.6 Ambulance Service involvement
South Western Ambulance Service saw Rachel on 6 occasions between 4th January 2021 and 3rd May 2021. They had been called by either Kay, Rachel herself or the police and for a range of both physical and mental health needs. The poor state of her home and her use of alcohol were noted on most occasions and on 3rd May 2021 a safeguarding referral was made to ASC in relation to her mental health needs. Rachel would follow the crew’s advice on some occasions and attend hospital or agreed to onward referrals but at other times she declined. Her mental capacity to consent to treatment and /or to be conveyed to hospital was assessed on at least 2 occasions during this earlier period and on both occasions, she was assessed to have the mental capacity to make an informed decision.
During the 12 months covered by this review the ambulance service attended a further 11 times:
6th April 2022- called due to mental health needs, Rachel appeared dishevelled and was assessed as not having mental capacity to consent to treatment. She was conveyed to hospital and a safeguarding referral made.
7th May 2022- Rachel appeared to have physical and mental health needs. Rachel was taken to hospital. A safeguarding referral was made in relation to self-neglect.
5th June 2022- The ambulance service responded to a concern for welfare from Kay. They had to access the property through an open window, Empty bottles of alcohol were noted. A safeguarding referral was made in relation to self-neglect and Rachel was taken to hospital.
5th July 2022- The ambulance service attended following a call from Kay, Rachel was expressing suicidal ideas and had physical needs. Faeces were noted on the floor and flies were inside the property. Rachel declined to go to hospital and was assessed as having the mental capacity to make this decision. A safeguarding referral was made.
12th July 2022- The ambulance service attended following concerns from the police about Rachel’s mental health. They again had to access the property through a window and took Rachel to hospital. A further safeguarding concern was raised.
4th August 2022- This call originated from the police as Rachel had stated she had taken an overdose. She refused to go to hospital and was assessed as having the mental capacity to make this decision.
5th August 2022- Rachel called the ambulance service stating she had taken an overdose. On being conveyed to hospital she attempted to leave the ambulance and the staff managed to calm her down. She refused to allow them to make any onward referrals to partner agencies. She was deemed to have the capacity to decline this support.
8th August 2022- Rachel called the service as she thought she had norovirus; on attendance she refused them entry and was assessed in the hallway. She refused to go to hospital and was assessed as having the mental capacity to be able to make this decision.
9th August 2022- Rachel called the ambulance service stating she had taken an overdose of her prescribed medication. The poor state of her home was noted, and she was taken to hospital.
15th August 2022- Rachel called the service due to both physical and mental health needs. She was taken to hospital.
30th October 2022- The ambulance service attended at the request of the police to confirm Rachel’s death at home.
The 5 calls in August activated the ambulance service’s frequent caller management system.
6.7 East Devon District Council
1st July 2022- approach received by Housing Options in relation to Rachel’s housing situation. This advised that she was in receipt of a section 21 notice due to expiry on 6th August 2022. Rachel’s landlord was seeking an eviction notice.
18th July 2022- email correspondence with Rachel who had approached the council in relation to a homelessness application.
29th July 2022- Rachel phoned for advice about her current housing situation. She was due to be evicted on 6th August 2022.
2nd August 2022- Housing officer called Rachel to book an appointment for a full housing assessment. Further advice re: the eviction notice was given. The same day Rachel rang back to say she has taken an overdose. Immediate safety advice was given.
During August 2022- there were a number of telephone calls to and from Rachel where she was unable to speak to her Housing Officer and when he returned her call, she was unavailable, and her phone did not seem to take messages. He was trying to book a further assessment and ensure Rachel is aware of the documents she needed to present. A further telephone appointment was made for 6th September which Rachel missed.
9th August 2022- Rachel’s Housing officer spoke to her landlord who provided additional information about Rachel’s home circumstances. She had not paid her rent since April 2022 and his view was that she was unable to safely live alone. He reported concerns about a blocked toilet and faeces in the property.
28th August 2022- Rachel’s social worker rung the housing officer to discuss future housing plans. She was advised that due to the difficulties in contacting Rachel there was a plan to close her housing application. The social worker advised that Rachel was very afraid as the section 21 notice had now expired.
6th September 2022- Rachel’s housing application was completed via telephone call.
26th September 2022- Rachel’s documents were received. Rachel confirmed she had made a claim for benefits as previously advised. She also advised that the court hearing in relation to potential eviction had been scheduled for 18th October 2022.
27th September 2022- Rachel’s housing risk assessment was sent to Sanctuary Housing to support Rachel and the housing officer suggested that a list of professionals working with her was obtained so that a multi-disciplinary meeting could be held.
27th September 2022- email from Rachel’s GP was received which expressed concern of “significant risk of death”. He asked about the possibility of sheltered accommodation.
5th October 2022- Landlord confirmed Rachel had paid her rent arrears but he was continuing with the court action for eviction.
7th October 2022- email to Rachel, with her Personal Housing Plan. Rachel advised her housing officer that she had had a job offer, that ASC had closed the safeguarding referral and that she was concerned about the pending eviction. There was a conversation about the need for a medical history from her GP.
13th October 2022- Sanctuary were asked to complete a face-to-face visit due to the escalating situation. The worker arranged the appointment for 20th October which was missed as Rachel had a hospital appointment.
18th October 2022- Landlord advised the Housing Officer that the court had granted the eviction which would take place on 1st November 2022.
26th October 2022- The Housing Officer made a safeguarding referral to ASC and was advised that a social worker would visit in the next 24 hours.
6.8 Devon and Somerset Fire and Rescue Service
6th April 2022- A referral was received from the ambulance service requesting a home safety visit due to the poor conditions in Rachel’s home. Referral advised that the property was cluttered, and Rachel had lost her front door key so couldn’t leave the property via the front entrance, The kitchen exit was blocked by rubbish. She was a smoker and had no working fire alarm. The referral was triaged by the fire service’s safeguarding team and passed to the home safety visiting team on 13th April.
9th May 2022- A second referral was received from the ambulance service. The details as above were given and a request for a visit from the Home Safety Team. The safeguarding team triaged the referral which went to the Home Safety Team on 27th May. The Home Safety Team rang Rachel on 27th May but were not able to get a reply.
12th July 2022- a third referral was made by the ambulance service. And a home visit was made to Rachel on 28th July 2022. Rachel declined the technician access as she said she had a “tummy bug”.
11th August 2022- Police ViST report was received by the safeguarding team detailing the very poor conditions in Rachel’s home.
31st August 2022- A technician visited Rachel and had a conversation through the front door. Rachel claimed she was moving soon and information about fire safety was left with her.
29th September 2022- A police ViST report was received by the safeguarding team and a Home Safety Visit requested due to Rachel’s living conditions.
6th October 2022- A technician visits for a third time. Rachel declined to give access as she stated she was unwell. Later the same day the technician called Rachel but was unable to get a reply and her phone did not appear to take a message.
7. What those working with Rachel knew of the home circumstances in which she was living
7.1 There were over 350 pages of information submitted from partner agencies which have been reviewed in order to complete this report. The detail provided above demonstrates clearly that each agency involved were aware of the conditions she was living in in the months prior to her death. The emergency services had visited the property on a total of 18 times in the 12 months this review covers and had completed safeguarding referrals and ViST reports advising partner agencies of the situation. Additionally, Kay, Rachel’s daughter made agencies involved very aware of the home circumstances her Mum with living in with frequent calls to both Adult Social Care, the Hospital, and the emergency services to alert them to a deteriorating situation.
7.2 The police made a ViST report to partners as early as 4th January 2021. On 10th May 2022 the police reported piles of post at the property. On 4th August 2022 there was explicit reference to the state of Rachel’s home including that fact that it was dirty, with empty vodka bottles noted. The police then referred to the Fire Service for a Home Safety visit and on 23rd September 2022 reported flies and other insects at Rachel’s home address. The Fire Service accepted a referral on the basis of Rachel’s poor and dangerous living conditions and despite the initial delay of 3 months did then attempt to visit her on three separate occasions.
7.3 As early as September 2021 the Royal Devon and Exeter Hospital reported concerns of self-neglect following a hospital admission, where Rachel had ulcerated legs which were not consistent with the explanation of the injury given. Each further attendance noted the concerns about self-neglect and indeed by 2022 the Psychiatric Liaison Team had taken a full social history that referenced the conditions Rachel was living in at home as well as her deteriorating physical and mental health. Frequently on admission her skin was damaged and required support from the tissue viability team. Similarly, it was well documented that Rachel was not taking her medication for both physical and mental health needs as prescribed, either missing days at a time or taking large amounts of medication in an attempt to harm herself.
7.4 Adult Social Care received a total of at least 7 safeguarding concerns from October 2021 -October 2022 all proving information that indicated evidence of self-neglect, with an earlier report from Rachel’s landlord on 22nd September 2021 that gave a detailed description of the very poor state of her home. This described a situation where Rachel had ulcerated and weeping legs, where she was not eating and was incontinent. She has also been embarrassed to let the landlord into her home.
7.5 Devon Partnership Trust made a safeguarding referral on 15th July 2022 on the basis of concerns about her home circumstances. Specific reference was made to self-neglect.
7.6 East Devon District Housing were aware that Rachel was being evicted from her home address due to the landlord’s concerns about the state of her property., hence her application for support with housing made in July 2022.
8. Information sharing about Rachel's home circumstances and signs of self neglect and whether these were recognised by practitioners and appropriate action taken
8.1 The information agencies have submitted as outlined above clearly demonstrates that there was a high level of information sharing. The police and ambulance services shared key information at times even when Rachel did not consent, as they understood the risk her situation and level of self-neglect presented. It was good practice that the GP, social worker DPT and the Fire Service all completed unannounced visits as the situation escalated.
8.2 Opportunities were missed by ASC as the lead agency for adult safeguarding on 22nd September 2021, when Rachel’s landlord raised concerns. Staff did not recognise self-neglect as a category of Safeguarding as defined in the Care Act 2014 and again on 13th January 2022 when a safeguarding concern was made in relation to self-neglect the concern was not progressed to an enquiry as Rachel had agreed to accept support on hospital discharge. This is despite Kay, her daughter highlighting the fact that Rachel would agree to support when in hospital, but then once home would change her mind. There was a clear misinterpretation of the term “proportionate” that did not recognise a pattern of behaviour which as early as January 2022 was becoming established. Similarly, when a further safeguarding concern was made on 13th June 2022, although it met the threshold to progress to an enquiry the decision was taken not to do so until Rachel was discharged home from hospital. The rationale for this decision was not given and it may have been that staff were concerned about causing a delay in hospital discharge but the lack of planning for Rachel’s return home lengthened her stay and did not recognise that this intervention was needed to fully understand how best to support a return home and in doing so prevent further deterioration and future admissions.
8.3 As early as September 2021 Rachel was admitted to hospital with pressure ulcers to her legs and this required specialist treatment and support. This was a regular concern on admission to hospital, but this was not seen as an indicator of the level of self-neglect she was experiencing. This was despite the fact that Rachel was fully mobile on the ward. Similarly, another frequent feature of her deteriorating health was attributed to her either not taken her medication correctly, leading to atrial fibrillation or her taking too much of her medication leading to potential intentional overdose. However, robust plans were not put in place and followed up to try to correct this.
8.4 Whilst agencies shared a great deal of information about Rachel’s home circumstances and the hospital and DPT and indeed Kay referred to “patterns” of incidents taking place it appears that patterns of behaviour were not seen as a sign of the level of risk Rachel was living with. The recorded information outlining specific patterns did not prompt practitioners to change and enhance the actions being taken to support Rachel and potentially reduce risk of continued self-neglect. Information about her high risk of homelessness and factors like the loss of her job and her deteriorating mental health which were shared were not jointly considered as increasing risk factors. Similarly, insufficient attention was given to understanding current and previous life trauma and working in a trauma informed way. The fact that the emergency services on occasion had to access the property by climbing through a window is another example of a building picture of risk. These life events were clear indicators that Rachel’s situation was deteriorating. No evidence of robust risk assessments has been provided by partner agencies as part of this review. Robust risk assessments would have given the opportunity to clarify the level of risk Rachel was experiencing and to plan accordingly.
8.5 There is evidence that after April 2022 access to Rachel’s property became increasingly difficult. She was either asleep or unable to answer the door when services attended, or she declined to allow people into her property. It was sometimes accepted that she had had C Diff previously and so when she declined support due to having diarrhoea this was accepted. Whilst this may have been the case it is also clear from information from her landlord for example that Rachel was embarrassed about the state of her home and increased professional curiously may have helped partner organisations to explore this further as a reason for her reluctance to allow people into her home.
9. The quality of inter-agency work and information sharing
9.1 The Individual Management Reports submitted by the agencies involved with Rachel demonstrate a high level of information sharing. Information was shared in the belief that other agencies would take action to improve her situation and reduce her risk of self-neglect. Achieving this requires a level of co-ordination and jointly agreed risk assessment and action planning which was not demonstrated in the case work undertaken. Agencies appear to have worked sequentially rather than in a holistic and co-ordinated way. An example of this was consideration of a multi-disciplinary meeting when Rachel was in hospital and plans were being made for her to return home. Professionals agreed it was required but no agency took responsibility for arranging such a meeting as each believed it was the responsibility of another partner. In reality any organisation can request and chair such a meeting, and this would have been an ideal opportunity to work with Rachel at a time when her health had improved, and she was agreeing to accept support on discharge. Organisations were under pressure at the time these events took place and COVID was impacting but resources and time pooled in working with Rachel would have led to better outcomes for her and a better use of scarce resources in terms of practitioner time. The use of a safeguarding strategy discussion/ meeting would have been another opportunity for professionals to meet to look at a protection plan for Rachel.
9.2 A lead practitioner was not identified to be a single point of contact to ensure agencies worked together well to support Rachel and link events that were taking place or to highlight patterns. The TDSAP has since developed Multi Agency Risk Management Meeting Principles and Guidance (MARMM) and templates which when fully implemented will address this need and provide a framework to support people working with complex situations including situations where people are experiencing self-neglect.
9.3 Robust multi-disciplinary working is also a helpful way to consider mental capacity and at various times agencies independently assessed Rachel’s mental capacity in relation to treatment, care and support needs, and information sharing. They did so in isolation and came to differing conclusions over the 12-month period of this review. In hospital she had been subject to a deprivation of liberty safeguard when acutely unwell, at other times she was assessed as having metal capacity around treatment and /or care and support needs and at other times her mental capacity was considered to be fluctuating. Whilst mental capacity is time and subject specific, as Rachel‘s health deteriorated a joint approach to assessment in this area could have enabled professionals to reach an agreed position. Staff recognised that executive functioning in relation to mental capacity was relevant due to both Rachel’s deteriorating mental health and her misuse of alcohol but did not pool their knowledge to make a decision around this.
9.4 Agencies have made reference to decisions to close their involvement with Rachel either because they felt she was not engaging with them or because they believed that she was able to take actions to improve her own situation. This was at a time when information sharing identified that her situation and both her physical and mental health were deteriorating, and her property was in an extremely poor state of hygiene. Regular multi-disciplinary team meetings would have shared this developing situation in a transparent manner allowing agencies to agree who needed to remain involved and how they would work together to monitor and retain an overview of the situation.
10. Family members views about the care and treatment Rachel received
Kay, Rachel’s daughter has been the lead family member in terms of providing information and important history for this Safeguarding Adults Review. She has willingly provided information to various agencies who have completed single agency reviews into their work with Rachel prior to this Safeguarding Adults Review being completed. Kay has worked hard to accept what has happened and been measured and reflective in her participation despite the level of concern she expressed whilst supporting her Mum over a long period of time. Whilst she understands the limitations partner agencies may have been under, she also feels that she was “sent round in circles” particularly in the weeks leading up to Rachel’s death. She agrees that professionals did not use the information they had to agree a joined-up plan of support and did not see the escalating risk due to life events such as Rachel loosing the job she loved. She described visiting Rachel at home and seeing her through her ground floor window talking to herself, appearing to be experiencing hallucinations and her and others having to climb through Rachel’s bedroom window to get her the support she needed. To Kay this was a clear sign of her Mum’s deteriorating mental health and yet professionals did not seem to acknowledge this or take her concerns seriously enough.
She noted that staff in hospital seemed to accept that it was inevitable that Rachel would be readmitted and seemed resigned to this. That these staff also seemed sad that they could not change or influence the system they were working in. On visiting the hospital Kay would often have to point out basic areas of care such as the fact that on a hot summer’s day Rachel was in a room that was 40 degrees and there was no window to open, or that her commode had been used but not emptied for long periods of time.
It was frustrating that on occasion a recommendation would be made e.g. the suggestion of supported housing but then Rachel would be discharged home again without actions being followed up. Kay expressed concern that she was unaware of Rachel’s diagnosis of emotionally unstable personality disorder and believes that Rachel was also not given this information which limited both their abilities to research, review and support each other to understand and manage this.
11. A comparison of lessons emerging from the SAR with improvements recommended by the Torbay and Devon SAP thematic review of self neglect
The thematic review was published in February 2023. The learning from this review for Rachel identifies a number of areas the thematic review recommended for action. These are:
11.1 That the TDSAP self-neglect guidance could benefit from review and content strengthened to remedy any gaps including a strengthened focus on family engagement. Staff in ASC did not recognise self-neglect as a category of adult safeguarding when initial referrals were received. A number of agencies did not understand or place enough emphasis on the reports from Kay. Patterns of concerns were identified but not addressed in a holistic way. A task and finish group has since been established by ASC and resources around self-neglect and good practice identified to support staff. The Lead Reviewer is aware that the TDSAP practice guidance update is currently work in progress as all partner agencies have learnt to adapt their practice in this area and will contribute to this update. Learning and enhanced practice from this Safeguarding Adults review needs to be delivered through the revised guidance.
11.2 That an audit of mental capacity practice is undertaken in cases of self-neglect, with a focus on executive functioning and measures taken to strengthen practice. As outlined above mental capacity and executive functioning was a concern in Rachel’s situation. To date, individual agencies have been asked to carry out audit work and DPT have completed an annual audit of 10 cases and their findings will come back to the Partnership. Other partners are yet to complete this work. Partner agencies have acknowledged in the panel meetings that this is an area that requires further education and training to strengthen practice across the system.
11.3 Seek assurance that practitioners and their managers are calling a multi-disciplinary meeting in high-risk cases of self-neglect. This review supports this recommendation and the MARMM work that the Partnership has agreed and is working on with partner agencies to operationalise. This will address practice concerns in this area. This is a key area of learning in relation to Rachel’s safeguarding adult review and needs to be completed as soon as possible.
11.4 Audit cases of hospital discharge where self-neglect is a feature. Self-neglect was repeatedly identified when Rachel was admitted to hospital and on discharge but the decision not to action the multi-agency meeting prior to discharge and not to progress the safeguarding enquiry until Rachel was at home are key areas where change is required. Similarly, the need for agencies supporting on discharge to recognise and flag when services previously agreed are declined is highlighted.
11.5 Provide guidance and training on working with people who are reluctant to engage. Rachel did engage with people trying to work with her but only at times when she was feeling well or when she recognised a point of crisis. Examples of this are when she was in hospital and agreed to support on discharge or when she reached out to East Devon District Council about her imminent eviction. She also rang her GP surgery when she felt unwell. Agencies looked for her to engage in ways that fitted their standard ways of working rather than understanding her specific needs. People with chronic mental health conditions and who are experiencing paranoid thoughts are less likely to respond to letters and /or telephone calls and more creative methods of engaging successfully with people with these needs may need to be considered. Staff also need to be persistent in their follow up with agreed plans of action.
11.6 Seek Assurance that supervision on such cases is as it should be. Information submitted for this review make some references to discussion with line managers and specialist safeguarding teams. Several organisations ceased their involvement with Rachel without sufficient rigor and reflective discussion.
11.7 Seek assurance from mental health and substance misuse service providers on how they are working individually and collaboratively in cases of self-neglect- Rachel was identified as someone who had an established misuse of alcohol and despite her history of not responding to offers of support or being able to follow up agreed actions, she was not formerly referred to service that support recovery from alcohol use. She was signposted to support but not proactively referred or supported to attend.
12. Summary and identification of learning points for partner agencies for action
Rachel had significant levels of contact with partner agencies as outlined above both before and during the 12 months prior to her death. These contacts tended to be dealt with as individual events rather than a continuum. When patterns were noticed by professionals and highlighted by her daughter Kay, agencies were consistent in sharing information but did not come together to complete joint risk assessment and risk management planning. There was no agreement as to who would take the lead for the work undertaken and insufficient attention was paid to co-ordinating the approach.
There was good practice identified in relation to the level of information taken to complete a social history particularly but DPT and the ward staff at Royal Devon and Exeter Hospital. The unannounced home visits undertaken by several organisations was also positive but there was a lack of persistence in following up required actions, and a reliance on the assumptions that Rachel would take actions to improve her home situation even when she had demonstrated that this was not the case.
It was good practice that a number of agencies had thought about executive functioning in relation to mental capacity around hospital discharge, but it took some time for this assessment to be completed by DPT and when it was, answers were taken at face value rather than understanding that Rachel’s previous failure to complete agreed actions was a sign of her inability to carry out the
decision.
The agencies listed below have already completed internal reviews of work undertaken and have held practitioner events or produced actions plans to address identified learning.
Adult Social Care
Devon Partnership Trust
Devon and Somerset Fire and Rescue Service
Rolle Medical Practice.
Their action plans include many of the areas listed above from the Thematic Review around self-neglect.
In addition to the above, the following are identified as learning points from this Safeguarding Adult review for agencies to consider:
1. For Partner Agencies to identify and agree a lead practitioner in complex cases of self-neglect so that that practitioner can co-ordinate information gathered, lead MDT and discharge meetings and work with persistence as both an advocate and a single point of contact. Relevant family/friends should be included in such a meeting and non-attendance from key partners should be escalated.
2. The need for chronologies and social histories to be utilised to identify patterns that an individual is presenting, to highlight signs that a situation is escalating and for agencies to respond in a way that encompasses trauma informed practice.
3. Where a case of severe self-neglect is identified agencies share their individual risk assessments so that one joint assessment can be used for multi-agency risk management. Agreement to cease involvement with an individual in such circumstances should be part of an MDT discussion.
Lead Reviewer: Fiona Davis is currently an independent adult safeguarding consultant. She has been a qualified social worker for 35 years and has worked as both a Principal Social Worker and in various Senior Management roles in Adult Safeguarding for a number of different Local Authorities.