SAR Tony

Glossary of terms

Torbay & Devon Safeguarding Adults Partnership (TDSAP) provides strategic leadership for safeguarding adults across Torbay & Devon as part of The Care Act 2014 statutory requirements. TDSAP is the collective name for partners across Torbay and Devon and acts as the key mechanism for agreeing how partner agencies work together to safeguard and promote the safety and wellbeing of adults at risk and/or in vulnerable situations. It does this by coordinating the operational work of TDSAP members and ensures this is done effectively.

The Care Act 2014 – helps to improve people’s independence and wellbeing. It makes clear that local authorities must provide or arrange services that help prevent people developing needs for care and support or delay people deteriorating such that they would need ongoing care and support.

Social Care Institute for Excellence (SCIE) – seeks to improves the lives of people of all ages by co-producing, sharing, and supporting the use of the best available knowledge and evidence about what works in practice.

SAR Quality Markers – a set of standards covering the whole process from initial decision making about whether a case meets the statutory criteria for a Safeguarding Adults Review, to evaluating the impact of actions taken in response to the learning identified.

National Network of SAB Independent Chairs – The Care Act established Safeguarding Adults Boards (SAB) in law. The Care and Support Statutory Guidance that accompanied the Act, set out expectations of those who chair Safeguarding Adults Boards. Where possible the chair should be independent, but this is not a requirement, and the network opened membership to all SAB chairs in 2016, having been set up as a peer support group for independent chairs in 2009.

Devon Integrated Adult Social Care – Social care staff who work with adults with care & support needs in Devon for whom activities of daily living (because of illness, older age, or a disability) can be difficult.

Care Act needs assessment – a structured process to assess potential need for day-to-day help.

NHS Devon Integrated Care Board/Partnership (ICB) – formally Clinical Commissioning Group (CCG). Integrated Care Partnerships (ICPs) are collaborative networks of service providers.  Commissioners of health care in Devon including healthcare professionals, such as doctors, nurses, pharmacists, social workers, and hospital specialists; the voluntary and community sectors; local council representatives; and service users and carers.

Royal Devon University Healthcare NHS foundation trust (RDUH) formally the Royal Devon and Exeter Foundation NHS Trust (RD&E). For the purposes of this report the Trust will be referred to as the RD&E as that was the Trust at the time of admission acknowledging however that any learning going forward will be for the RDUH and thus named as such in the recommendations. Tiverton Community Hospital falls under the RDUH.

Residential Care Home – The time parameters for this review includes a period where Tony was a temporary resident at a Residential Care Home (RCH). References to this temporary placement will be shown as ‘residential care home’.

* Any reference/link with asterisk, please refer to list of references on pg. 16

1. Introduction to a Safeguarding Adults Review

1.1 The Torbay & Devon Safeguarding Adults Partnership (TDSAP) commissioned a safeguarding adults review (SAR) into the death of Tony, aged 89, who died in Derriford Hospital on the 7th February 2021.

1.2 Following the initial referral by Devon Integrated Adult Social Care, the TDSAP Safeguarding Adults Review Core Group, a subgroup of TDSAP, responsible for overseeing the referral & management of SARs across Torbay & Devon, believed that the circumstances leading up to his death met the statutory requirements for a Safeguarding Adults Review under Section 44 of The Care Act 2014.

‘A review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if –

a. there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and

b. the adult had died, and the SAB knows or suspects that the death resulted from abuse or neglect…’

1.3 A lead reviewer was appointed to work with relevant agencies to identify areas of learning to improve partnership working and to minimise the possibility of a reoccurrence, as per s.44(5) The Care Act

1.4 This review has attempted to follow as far as possible the Quality Markers for Safeguarding Adults Reviews as produced by Social Care Institute for Excellence (SCIE) and the National Network of Safeguarding Adults Board Independent Chairs.

1.5 The lead reviewer is a retired Police Chief Superintendent, Devon & Cornwall Police, a former Head of Public Protection & Independent Safeguarding Adults Board Chair. There are no links with any of the agencies who have participated in this review process which would undermine independence.

1.6 Tony leaves behind a wife, Anne, a daughter & a stepdaughter. Tony’s family, particularly his wife has played a valuable role in this review, providing valuable information to enable this review to understand Tony as a person and provide an understanding of how services provided to Tony impacted not only on him, but his family also.

2. Review methodology

2.1 A Safeguarding Adults Review is more than a written report. It is a process which galvanises people & organisations who worked/are working directly with people who needed/need support to have a ‘duty of candour’*, how they are open to learning, identify where improvements can be made & are transparent in recognising barriers to effective practice.

2.2 An analysis of the Care & Health Improvement Programme led thematic work of SARs (2020, Preston-Shoot, Bray et.al) identifies key elements of an effective SAR.

• Legal literacy as to when a SAR is required (mandatory) or where it is believed valuable learning is beneficial to the safeguarding system (discretionary)
• Open, detailed & timely responses by agencies documenting not only the extent of their engagement with the person, but an openness in identifying learning at an early stage.
• Effective communication & involvement with/of family members or those representing the family of the person subject to the review.
• A process where the lead reviewer can engage with practitioners and managers, either individually or as a group where systemic analysis can take place.
• A review where there is good concordance between rationale for referral, terms of reference & identification of key areas through the above analysis.
• Drawing on learning from previous SARs where similar issues were identified.
• Areas of learning & recommendations that are co-produced, evidenced-based, learning focused & timely. Reviews should not ‘shy away’ from proposing system improvement regionally and/or nationally where appropriate.

2.3 The review into the death of Tony has been identified as a mandatory SAR. Although not formally being provided with care & support as defined under The Care Act 2014, it is recognised through initial analysis of agencies responses that Tony was a person who required care & support, and there was reasonable cause for concern about how partnership members or other persons with relevant functions worked together to safeguard Tony.

2.4 The documentation from agencies, through an Appendix 2*, Individual Management Report (IMR)* or other documentation allowed the lead reviewer & panel members to identify key areas of focus for further analysis, identified areas where learning could be implemented, and were open in how the safeguarding process could have been improved.

2.5 This review did not include a multi-agency practitioners’ event, primarily due to a linear timeline where different partners were supporting Tony in different phases of his care.  However, the positive engagement of agency representatives both in formal SAR Panel meetings and individual discussions with the lead reviewer, particularly around key learning themes and co-production of recommendations has overcome the potential direct learning from a practitioner’s event.

3. Background to Tony

3.1 Tony, a white male, had a successful & varied career, primarily as an electrical engineer. He served on 2 tours of HMS Belfast, and then as a maintenance manager for Selectro. From 1993 until his return to the UK in 2008, he spent his life in France. Furthermore, Tony had previously owned his building business.

3.2 Tony has been described as a very patient man, one who was practical, supportive, independent, and easy going.

3.3 Over a number of years, both in France and in the UK, Tony was diagnosed with a number of serious illnesses, including bladder cancer, chronic obstructive pulmonary disease & rheumatoid arthritis. These long-term illnesses & usage of prescription drugs and medical interventions over a number of years may have impacted on a sharp decline in Tony’s health over the last few years of his life. His mobility worsened, he experienced visual disturbances, decline in memory & became noticeably frailer.

3.4 With a noticeable change in frailty, Tony became vulnerable to falls, exacerbated by the further diagnoses of osteoarthritis in September 2017 & postural hypotension in February 2019.

3.5 Tony leaves a wife, Anne. Anne has been very much involved in allowing the review to build a picture of not only Tony as a person, but how the health & social care system has responded to Tony as a patient/client and herself as a carer.

3.6 Tony died in February 2021. At this time, the UK was in its 3rd lockdown period of the covid19 pandemic. Tony’s death at Derriford Hospital was preceded by a 3-month period where he was initially admitted to the Royal Devon & Exeter Hospital (RD&E) emergency department, an inpatient at Tiverton Community Hospital, and a short stay at a residential care home. It goes without saying that this period of time was part of an unprecedented landscape worldwide, with the NHS and care homes at the forefront of society’s response. Although the safeguarding of vulnerable people such as Tony would have remained at the forefront of medical and care home staff & managers, working practices were fundamentally changed through Government policy, legislation & guidelines. This did not just impact on individuals in need of care, it impacted on loved ones. This impact was clearly demonstrated in my conversations & messages with Tony’s family. Although Tony contracted covid during his time in hospital, there is no suggestion that this contributed to his death. However, the wider implications of how Tony & his family were affected by decisions taken nationally did impact on the family as a whole.

4. Timeline to key events

22/11/2020 Following a 999 call, paramedics conveyed Tony to RD&E Hospital emergency department via ambulance. Although the admission was not directly related to a fall, there were ‘concerns around worsening mobility, reduced appetite, and a urinary tract infection’. Tony was then subsequently admitted to acute ward initially at RD&E Hospital.

30/11/2020 Tony transferred to Tiverton Community Hospital for ongoing rehabilitation. Urinary & acute kidney symptoms also identified.

13/12/2020 Tony identified as a ‘covid19 contact’, later confirmed as covid19 positive.

18/12/2020 During the period of being an inpatient in Tiverton Community Hospital, Tony fell, fractured his hip. He was transferred to RD&E Acute Hospital for surgery.

01/01/2021 Tony was transferred back to Tiverton Community Hospital for ongoing rehabilitation.

22/01/2021 Tony was transferred to a residential care home for ongoing rehabilitation.

03/02/2021 Tony was admitted to Derriford Hospital, University Hospitals Plymouth following a possible dislocation of new prosthetic hip joint.

05/02/2021 Emergency left girdlestone surgery. A girdlestone procedure is a type of surgery performed on individuals experiencing severe, painful hip conditions, and is generally only used in circumstances where no other options are viable.

07/02/2021 Tony died at 0845.

12/9/2021 Inquest heard before Ian Arrow, HM Coroner. Record of inquest detailed medical cause of death as

1a Sepsis.

1b Pneumonia.

2 Hip dislocation.

5. Overview of key lines of enquiry

5.1 Following Tony’s death, a detailed letter of complaint was sent to a number of agencies that had been involved in Tony’s care from his admission to the RD&E Hospital on the 22/11/2020 to his death on the 7/2/2021.The organisations have all provided a response to this letter of complaint.

5.2 Furthermore, the RD&E Trust carried out an ‘amber investigation’ regarding a fall that Tony suffered whilst in Tiverton Community Hospital. Given, that at this time, single agency involvement at this time, an investigation has taken place together with an action plan, this element has not been included as a key line of enquiry for this review.

5.3 There are 2 issues however, where the TDSAP may wish to seek assurance that the Trust has followed through on its commitments.

5.4 The Trust produced an action plan following the investigation into Tony’s fall in Tiverton Community Hospital. This was disseminated to a wider internal audience. According to the Trust’s documentation submitted to this review, all actions in the plan should have been completed by May 2021. It is recommended that the TDSAP seeks assurance that this action plan has been completed given the time that has elapsed, and the intended changes embedded into practice.

Recommendation 1. Within 3 months of publication, the Royal Devon University Healthcare NHS Trust provides assurance to the Torbay & Devon Safeguarding Adults Partnership that the action plan developed following the amber investigation into Tony’s fall in Tiverton Hospital on the 18/12/2020 has been fully embedded into working practice across the Trust sites. This assurance should include examples as what action has been taken to reinforce or improve patient safety systems.

5.5 On the 15th March 2021, the RD&E Trust wrote to Anne informing her that a formal investigation into Tony’s fall at Tiverton Community Hospital had been completed and that the report was due to be signed off on the 25th March 2021.

5.6 On the 29th March 2021, the Trust again wrote to Anne, informing her of the outcome of the amber investigation, which found that Tony’s fall was ‘unavoidable.’

5.7 On the 20th September 2021, the Trust’s Chief Medical Officer wrote to Anne with a wider response to the concerns in her original letter of complaint.

5.8 The lead reviewer has sought information from the Trust that Tony’s family were informed of this investigation from the outset. At the time of the writing of this report, the Trust has not confirmed this to be the case.

5.9 In a jointly produced report by NHS England, Healthcare Safety Investigation Branch & Learn Together (Supporting involvement after safety events in healthcare), entitled ‘Engaging & involving patients, families & staff following a patient safety incident’*, August 2022, the need to involve families in investigations is clearly set out:

Many national reports clearly articulate the importance of engaging with patients, families, and staff appropriately after a patient safety incident and involving them in any subsequent investigation. While healthcare organisations have undoubtedly increased their focus on engagement with and involvement of patients, families and staff, the way they do this in patient safety incident investigations remains varied. Many of those affected still feel excluded from the process. (pg.3)

5.10 A common feature of Anne’s letter to agencies was a lack of communication.

5.11 The need to provide meaningful engagement with patients & families is not limited to openness & transparency but can also contribute to the minimising of risk.

‘… engaging with those affected by a patient safety incident substantially improves our understanding of what happened, and potentially how to prevent a similar incident in future.’ (pg.5)

5.12 Locally, The Torbay & South Devon Foundation Trust have introduced a ‘hot debrief’ process where falls are initially investigated within the same shift and includes patient and family views. Furthermore, ‘after action reviews’ are carried out for moderate & above risk as well as for patients identified as repeat fallers. This process is recommended by the Royal College of Physicians following a national inpatient falls audit.

Recommendation 2 Within 6 months, the TDSAP seeks assurance from partners required to respond to patient safety incidents that communication with patients & families during single agency reportable patient safety incidents is based on using information from patients & families to improving patient safety. (The TDSAP may wish to use the above document as a basis for this work.)

5.13 From an analysis of the documentation provided to the review from agencies, engagement with Tony’s wife, & discussions with agencies representatives, the following areas have been identified as a key line of enquiry.

• Tony as a person vulnerable to falls.
• Transition for adults with social care needs between hospital settings & community or care homes.
• Ongoing demands on Tony’s wife, Anne as a carer & replacement care.
• Impact of national guidelines/policies & decisions in relation to the covid19 pandemic.

6. Tony as a person vulnerable to falls

6.1 Tony’s vulnerability to falls was a constant risk for some time prior to his admission to the RD&E Hospital on the 22^nd November 2020.

6.2 The Appendix 2 submitted by The Southwest Ambulance Service Foundation Trust identified 3 occasions where they attended Tony’s home due to a fall, the earliest being 27^th July 2019.

6.3 The Bow Surgery documentation identified that Tony was on their ‘severely frail register’, had recurrent falls, and in September 2017 was diagnosed with osteoarthritis, a type of degenerative joint disease resulting from a breakdown of joint cartilage & underlying bone. Symptoms of osteoarthritis include weak & painful joints which can result in impaired mobility. The diagnosis of postural hypotension in February 2019, would have further increased Tony’s risk of falls. Postural hypotension (also called orthostatic hypotension) is a drop in blood pressure when you stand up after lying or sitting down.

6.4 There is evidence in agencies responses that although identified as a person vulnerable to falls, the timeliness of support was slow. An example of this is shown at 9.3(i) where a request for a second shower rail was delayed due to the second lockdown period. Although working practices were different throughout the pandemic, it has to be questioned why a further assessment was required when one had been carried out only 3 weeks earlier.

6.5 As already included in the timeline, Tony suffered a fall as an inpatient in Tiverton Community Hospital and also at the residential care home.

6.6 During his stay in the RD&E Hospital, Tony had a cognitive assessment, which identified some cognitive concerns. On the 26^th November 2021 a falls risk was carried out and a Level 2 Falls Plan was implemented. Following this fall, a CT Head scan was performed, which showed some degenerative changes. Furthermore, lying & standing blood pressure readings showed there was a ‘postural drop’, which is likely to have caused a greater imbalance on standing due to the dizziness caused by this drop.

6.7 Over the first few days of his time in Tiverton, Tony was reported to be very restless, unsettled & at times non-compliant, with using the call bell. A sensor tag lanyard was put in place. A sensor tag lanyard is a small box which is attached to the seating or bed and then has a clip attached to patient. If patient stands the disk in the box is pulled out emitting an alarm to alert staff that the patient is moving.  However, Tony would remove this himself in order to mobilise, particularly relating to a sensor tag lanyard. Tony was placed in a more visible bay & provided with sensor mats placed on his bed & chair in addition to the sensor tag lanyard. Sensor mats alert staff to patients being up and mobilising who need assistance but who are not able to use the call bell consistently or appropriately. However, depending on the patient’s ability, impact of postural drop, the distance of the responding staff and, at this time in the pandemic, the need to don PPE the time lag can be insufficient to reach the patient before they fall. Tony’s moving and handling assessment identified that he needed the assistance of 1 to mobilise at all times.

6.8 On the 18^th November, Tony alerted the nurse of his need to go to the toilet. She asked him to remain seated whilst she was donning PPE, however she then heard a thud when Tony fell to the floor. An assessment confirmed a fracture to his left hip and Tony was transferred back to the RD&E Hospital for surgery.

6.9 On the 3^rd February 2021, as a resident at a residential care home, Tony was admitted to Derriford Hospital following a possible dislocation to his new prosthetic hip joint.

6.10 Both the RD&E Trust and the residential care home have sought to improve patient/resident safety following Tony’s experience with them.

6.11 The RD&E Trust identified that ongoing monitoring of falls risk as patients moved wards or teams was a factor to include in the aforementioned action plan. Actions to improve patient safety included:

• No documented evidence of why falls prevention measures were discontinued when the patient moved wards across the RD&E Trust.
• Falls risk should be reassessed when there are changes to the patient’s health, presentation or behaviour in order to optimise prevention interventions.

This should be a focus of attention for the TDSAP in recommendation 1.

6.12 The residential care home has also purchased additional equipment to support people who have fallen. A Manger cushion, an electronic pillow, enabling the patient to be lifted from the floor to a seated position and bucket hoist slings which are allocated to each resident on admission. If they were to fall, and it was safe to do so, the person could be hoisted from the floor in this. Regular manual handling practices and first aid training continue to take place, particularly with managers who are competent in carrying out basic checks for injuries after falls.

6.13 As at 6.3, Tony was diagnosed with postural hypotension in February 2019 Both diagnosis & medication clearly indicates that Tony was vulnerable to dizziness and falls. Together with other multi morbidities, the presence of 2 or more long-term health conditions, which can include frailty & chronic pain, this risk was exacerbated.

6.14 Although Tony had fallen both in hospital and care provider setting, the earlier risk was in his home. According to the South West Ambulance NHS Trust, concerns around mobility & vulnerability to in the home that led to his initial hospitalisation.

6.15 The Department of Health & Social Care calculate that hip fractures alone in the UK account for 1.8 million hospital bed days & £1.1bn in hospitals costs each year, excluding the cost to the social care sector.*

6.16 The document further highlights that people aged 65 and older have the highest risk of falling; around a third of people aged 65 and over, and around half of people aged 80 and over, fall at least once a year.

6.17 The costs are not limited to financial ones, short and long-term outlooks for patients are generally poor following a hip fracture, with an increased one-year mortality of between 18% and 33% and negative effects on daily living activities such as shopping and walking.

6.18 In 2017/18, NHSE England introduced routine frailty identification of patients aged 65 & over as part of GP contracts.* Linked to this were a targeting of a small number of interventions such as falls assessments, medicines review & the promotion of the additional information in the summary care record. This change was focused on those most at risk of adverse events including hospitalisation, nursing home admission and death.

6.19 The Torbay Health & Wellbeing Board in its 2022-2026 Health & Wellbeing strategy* has as one of its goals under its Healthy Ageing priority:

‘Improving physical fitness & reducing risk of injury from falling from frailty.’

6.20 Although the Devon Health & Wellbeing Board’s strategy 2020-2025* does not have any specific reference to risk of injury from falls or frailty, it has references to supporting people with long-term conditions to maintain a good quality of life under its priority, ‘Maintaining good health for all. Supporting people to stay as healthy as possible for as long as possible.

6.21 The TDSAP has undertaken significant work with agencies such as the Devon Care Home Collaborative in developing guidelines for providers of health & care services around falls & safeguarding. In November 2022, the TDSAP published a document entitled, ‘Falls & safeguarding. Guidance for organisations who provide care & support’.* Primarily this document was directed to registered care providers who provide such support to adults at risk to ensue appropriate safeguarding referrals were made, particularly in relation to falls. This document also signposts to further guidance from bodies such as the care inspectorate and CQC in how to deal with fall events.

6.22 Given that amongst Tony’s specific vulnerability, risk of falling was a dominant feature in his later life, and the local & national impact on health & social care organisations and people such as Tony, there are opportunities for the health & wellbeing systems across Devon & Torbay, including the TDSAP to consider whether the service provision for those deemed to be severely frail is effective & commensurate with demand.

6.23 Questions for the health & being system are:

• Is there an understanding of the prevalence of injury due to falls for those deemed to be severely frail?
• Is there assurance that the current service provision meets demand?
• Is there consistency in practice within primary care when a person has been identified as severely frail?
• Is the provision of social care assessment & support consistent, timely and meets the need of the individual?
• Is current service provision routinely reviewed to ensure it meets emerging trends or an increase in demand?
• For those who are deemed to be severely frail and where there is an incidence of falls (one of the five frailty syndromes), where does the responsibility lie for assessment with interventions aimed to reduce or delay frailty or, as a minimum, ensure that people living independently have timely interventions to minimise falls and a falls strategy in place to be able to raise the alarm and gain help as required

6.24 Devon Integrated Care Board has recently developed a stronger approach to frailty through work led by Dr. David Attwood, Strategic Clinical Adviser for Older People in Devon Integrated Care System. An outcome of this work is a handbook for designing & commissioning integrated services that support healthy ageing.*

6.25 It is recommended that the TDSAP considers how it can build on the Falls & Safeguarding guidance, and in conjunction with the 2 Health & Wellbeing Boards and Devon Integrated Care System, to understand the prevalence of injuries and hospital admissions due to falls by those people deemed to be severely frail, and to support clinicians & commissioners to review current service provision from that initial research.

Recommendation 3 Within 6 months, The TDSAP works with the Torbay & Devon Health & Wellbeing Boards and the Devon Integrated Care System to understand the prevalence of injuries due to falls by those people deemed to be severely frail. This analysis to then inform whether current frailty provision across Devon & Torbay is commensurate with the risk of falls & fractures or to identify service provision gaps.

7. Transition for adults with social care needs between hospital settings & community or care homes

7.1 Following periods of being an inpatient at both RD&E Hospital & Tiverton Community Hospital, after being clinically assessed as being suitable for ongoing care & assessment outside an acute setting, Tony was transferred to a residential care home.

7.2 The process of discharge & location will be further analysed in a later part of the report, ‘Impact of the covid19 pandemic’.

7.3 Tony was discharged to the residential care home following a Pathway 2 referral. A Pathway 2 discharge is for ongoing reablement rather than a D2A (Discharge to Assess) assessment for longer term care & support needs. This discharge to the residential care home was for an initial period of 6 weeks to allow reablement to be carried out, following which, a further assessment would take place to assess whether Tony required a longer-term placement or had regained a good level of previous ability that would reduce risks enough for him to be supported to return living in his own home.

7.4 Consequently Tony became a temporary patient in respect of the 2 GP practices that had been involved in/about to become involved in his primary care.

7.5 The process of transference of care between the 2 GP practices were included in the detailed letter of complaint submitted by Tony’s wife, Anne where she questioned whether the transfer of care, particularly medical records impacted on the clinical care provided to Tony.

7.6 The ‘incoming’ practice did have limited access to electronic records and for example subsequently increased Tony’s dosage of Fludrocortisone. This was based on the previous diagnosis of postural hypotension and observations of Tony’s recent significant drop in blood pressure, a likely cause of his dizziness.

7.7 Anne also referred in her complaint to a home visit by the GP to Tony following a shortness of breath. Although the attending GP agreed to prescribe amoxicillin on that day, a Friday, this plan did not start until the following Monday.

7.8 The GP practice has been open in this review & to HM Coroner that this was a mistake and has disseminated key information within the practice to minimise the risk of this reoccurring.

7.9 Furthermore, the residential care home has put in place some actions to improve patient safety around medication prescribing. As well as ensuring a staff member accompanies the GP when visiting residents & prescribing medicines, they now use a pharmacy that has extended opening hours to ensure medication is available as early as possible. The care home also has a process, where on admission, they request a GP summary from the patient’s own surgery which is then checked to ensure information is carried across to the care home’s records and new practice.

7.10 In August 2022, The Somerset Safeguarding Adults Board (SSAB) carried out a Learning Event together with a practice briefing around a care home resident who had been transferred between providers in Somerset & Devon. Then known as The Devon Safeguarding Adult Board, it also received a SAR referral for the same individual. Key features of ‘Mrs. L’s’ review included flaws in prescribing medicine, GP registration & communication with families.*

7.11 Related to ‘Mrs. L’s’ review, in October 2022, the TDSAP produced a guidance document on Medicines Management.* Both the GP practice & the residential care home have strengthened their processes, & although the error in Tony’s case is rare, both GP’s and registered providers have a shared responsibility in ensuring the right medication is given at the right time. Given the similarities between this review and ‘Mrs. L’, it is recommended that the TDSAP remind their provider sectors of the guidance and re-emphasise by circulating it via its provider networks along with the practice briefing produced by the Somerset Safeguarding Adults Board.

Recommendation 4 Within 3 months of publication, the TDSAP disseminates both the Medicines Management guidance & the Somerset Safeguarding Adult Board practice briefing relating to ‘Mrs L’ to their provider sector partners via provider & primary care networks.

8. Ongoing demands on Tony's wife as a carer

8.1 It is evidently clear that not only had Tony’s illnesses & decline had a devastating & debilitating impact on him, but it has also caused stress, frustration & despair with Anne, who was also Tony’s full-time carer.

8.2 There is evidence when reviewing the responses of partner agencies that more than one recognised that Anne’s needs as a carer were ignored.

‘His wife was struggling to cope and was concerned he would continue falling.’

‘He was cared for by his wife Ann who appropriately contacted the surgery when she had concerns regarding her husband. In the year preceding his admission and taking into account the effect of COVID on our practice, Tony was seen in person on 12 occasions, there were 28 telephone calls and 2 home visits. Prompt action by Ann in contacting the surgery, in my opinion, prevented admission to hospital on numerous occasions.’

‘His wife asked for help for personal hygiene, as she currently struggles to assist.’

‘His wife finds it hard to accept changes to the set-up of the bedroom.’

‘When undertaking an assessment or contact, the practitioner should always consider the impact of the carer.  In this case the carer was completing caring tasks for her husband, but the assessor only focussed on what amount of ‘formal support’ the carer asked for.’

8.3 In discussions with Devon Adult Social Care managers, the absence of consideration of the carer is not believed to be common practice, and there is no evidence that this is a systemic flaw.

8.4 This frustration was also clearly evident when the lead reviewer met Anne.

‘I got lost, so many departments involved. It was difficult. They don’t get behind how the carer is presenting’.

‘I felt overwhelmed. I was scared I couldn’t manage him.’

‘It was stressful. I didn’t realise how stressful it was until it stopped.’

‘I didn’t raise this as I was just fed up with everything.’

8.5 Accessing care was also problematic for Anne. The recording of observations on DCC Integrated ASC Anne as a carer did not accurately reflect her needs nor any subsequent action that was taken. Responses from ASC indicate that any observation directly or indirectly to Anne as an unpaid carer were recorded on Tony’s record as the ‘cared for’ person. According to ASC, it is not possible to determine whether Anne was identified on CareFirst* as an unpaid carer.

8.6 Devon County Council Integrated ASC has introduced a new system that recognises that initial contact into their care system can be improved. They have moved from a 2-stage process where previously a call for advice, information or assessment was initially triaged by a team within the Devon County Council Customer Service Team (sitting outside ASC) to one where the initial call is received by Care Direct Plus. It is believed that this newer process will reduce the number of times a person is required to ‘tell their story’, and the quality of advice and timeliness of activity will improve.

Recommendation 5 Within 6 months, Devon County Council Integrated Adult Social Care provides assurance to the Torbay & Devon Safeguarding Adults Partnership that changes to initial contact into their care system is realising the intended benefits of improving access to their care system, including quality of advice, timeliness, and needs of unpaid carers.

9. Impact of national guidelines/policies & decisions in relation to the covid 19 pandemic

9.1 In June 2022, The Government set up the UK covid19 inquiry. Included in the aims of the inquiry* are:

a) consider any disparities evident in the impact of the pandemic on different categories of people, including, but not limited to, those relating to protected characteristics under the Equality Act 2010.

            The public health response across the whole of the UK, including:

• the availability and use of data, research, and expert evidence.
• legislative and regulatory control and enforcement.
• shielding and the protection of the clinically vulnerable.
• the impact on the mental health and wellbeing of the population, including but not limited to those who were harmed significantly by the pandemic.
• the impact on the mental health and wellbeing of the bereaved, including post-bereavement support.
• the impact on health and care sector workers and other key workers.

            The response of the health and care sector across the UK, including:

• the role of primary care settings such as General Practice.
• the management of the pandemic in hospitals, including infection prevention and control, triage, critical care capacity, the discharge of patients, the use of ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions, the approach to palliative care, workforce testing, changes to inspections, and the impact on staff and staffing levels.
• the management of the pandemic in care homes and other care settings, including infection prevention and control, the transfer of residents to or from homes, treatment and care of residents, restrictions on visiting, workforce testing and changes to inspections.
• care in the home, including by unpaid carers.
• Identify the lessons to be learned from the above, to inform preparations for future pandemics across the UK.

b) listen to and carefully consider the experiences of bereaved families and others who have suffered hardship or loss as a result of the pandemic. Although the Inquiry will not consider in detail individual cases of harm or death, listening to these accounts will inform its understanding of the impact of the pandemic and the response, and of the lessons to be learned.

9.2 An analysis of the National Network for Chairs SAR Library identifies between 30 & 40 reports relating to adults with care & support needs where the pandemic was a feature of the review.

9.3 The impact on individuals, families, practitioners, and organisations cannot be overestimated and this impact has been evident in Tony’s review. Within this review, there are specific examples where the response to the pandemic has affected the care & support provided to Tony and Anne, of which no blame is apportioned, but influenced or directed by national policy, guidance, or legislation.

• The timeliness of assessments & support in the home caused by lockdowns. For example, when Anne on the 12^th November 2020, requested a second support rail in the shower, she was informed that there would be a delay in an assessment due to the second lockdown period.
• The discharging of Tony from Tiverton Community Hospital to a care home, some 40 miles from his home. At this time The Government’s priority as set out in discharge policy was focused on people leaving hospital quickly, meaning that priority was first available care home rather than first choice or preferred choice.
• Minimal physical contact between Tony & family due to visiting restrictions on care homes & hospitals. This led to stress & frustration on Tony’s family and led to profound upset that they did not see Tony before he died.
• Communication between Tony & family, and subsequently family and health/social care organisations leading to long distant & at times misleading or misunderstood information being received or interpreted. For example, Anne and her daughter was seeking for Tony to be designated as ‘end of life’. This request was predominantly due to visiting rights for such individuals in hospitals & care settings allowing physical visits. I am grateful for the representative from University Hospitals Plymouth NHS Trust in explaining in detail what ‘end of life’ means for a patient. It is clear that ‘end of life’ designation and the removal of medical interventions would not be appropriate for Tony at that time. It is unclear how this was communicated with Tony’s family.

9.4 There are opportunities both locally & nationally to learn from the devastating impact of the pandemic on individuals, families, practitioners & organisations.

9.5 In its Annual Public Health Report 2020-2021*, Devon Public Health’s sole focus is on the impact of the pandemic together with a list of recommendations including lessons to be learnt to inform how partners prepare for & respond to future communicable disease outbreaks.

9.6 In a letter, dated 15^th March 2021, The Royal Devon & Exeter Hospital wrote to Anne informing her that the wider Trust would be carrying out a serious incident investigation to determine:

• The significant contributory factors of hospital acquired covid19 at the Royal Devon and Exeter NHS Foundation Trust
• Whether there was a missed opportunity to detect an outbreak at an earlier stage and if so the root cause(s) of this.

9.7 Practitioners & managers have commented that despite the adverse impact of the pandemic on them & those they care & support for, there are examples where working practices have enabled improved partnership working.

9.8 Questions posed to Newham Safeguarding Adult Board from a review into the death of ‘Peggy’* in relation to safeguarding of adults & the pandemic equally apply to TDSAP partners:

• What are the plans for assessing which of the new ways of working developed in response to Covid, that are to become standard?
• How can opportunities to innovate be sustained?
• Is there scope for further innovation and creativity to streamline or combine respective agencies’ assessment requirements and support a collective understanding of the interplay of a person’s needs and issues?

9.9 A theme readily recognised across partners in Torbay & Devon is the pressure on staff during the pandemic. A recommendation for Barnet Partnership regarding this area in the ‘Anne’* review is.

‘The overwhelming pressure on staffing levels during the pandemic reduced the efficacy of supervision processes, resulting in episodic analysis of information. Recommendation: The Board must seek assurance from all partners that contingency plans during periods of crisis focus on effective supervision of staff, including agency staff.’

9.10 Although there are a number of reviews relating to the pandemic, both locally & nationally, a theme which the TDSAP should seek assurance around is learning around the safeguarding of adults with care & support needs, a cohort who were heavily impacted on due to covid19.

Recommendation 6 Within 6 months of publication, the TDSAP as part of its planning cycle, considers how learning from the Covid-19 pandemic can improve the safeguarding of adults with care & support needs, including how it can be assured that partners contingency plans during periods of exceptional demand maintain the safeguarding of this cohort of vulnerable people.

9.11 The TDSAP’s current business plan ends in 2024. As part of the process for a new plan, it may wish to consider how the safeguarding of adults with care & support needs can be improved through learning from examples of innovation & areas for improvement from the pandemic across the Partnership landscape. 

Recommendation 7 Within 3 months, the chair of the TDSAP starts a discussion amongst regional & national chairs as to how learning from safeguarding adults reviews can be collated & disseminated at a national level, whether that is through the national network engagement with The Department of Health & Social Care or the UK Covid19 inquiry.

 

10. Appreciation

10.1     I would like to thank the agencies who have contributed to this review. I have found them to be open to how the safeguarding system across Devon & Torbay could be improved in the light of reviewing their own offer to Tony. I would also like to thank Tony’s wife Anne for providing valuable information on Tony’s background. Without her help, this review would not be able to give it the context of not only Tony’s experience of the care he received in the last few months of his life, but also how she as his carer had to meander her way through a health & care system that can be confounding & frustrating.

11. List of references

2.1 ‘Duty of candour’ – Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. (General Medical Council, The Professional Duty of Candour)

2.4 Appendix 2’s – The purpose of the Appendix 2 is to gain an overview of events and changes in an adult’s life, including any relevant information regarding their wider family including any children they parent or care for.

2.4 Individual management report – The aim of the individual management report is to review the circumstances at the time; and to develop an open critical analysis of both individual practice and organisational policy and practice, to see whether the case indicates that changes can and should be made.

5.9 NHS England, Healthcare Safety Investigation Branch & Learn Together (Supporting involvement after safety events in healthcare), ‘Engaging & involving patients, families & staff following a patient safety incident’, August 2022.

6.15 Office for Health & Improving Disparities (www.Gov.uk) Falls. Applying to all our health, Feb 2022.

6.18 https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/frailty-risk-identification/

6.19 Torbay Joint Health & Wellbeing strategy 2022-2026. https://www.torbay.gov.uk/council/policies/health/joint-health-and-wellbeing-strategy

6.20 Devon Joint Health & Wellbeing strategy 2020-2025. https://www.devonhealthandwellbeing.org.uk/strategies/

6.21 Torbay & Devon Safeguarding Adults Partnership. Falls & safeguarding. Guidance for organisations who provide care & support, November 2022.

6.24 Commissioning services to support healthy ageing in Devon’s localities: Building the blueprint – YouTube

8.5 The IT system used by Devon Integrated Adult Social Care to provide case management on individuals supported by their adult social care teams.

7.10 Somerset Safeguarding Adult Board. Practice briefing ‘Mrs L’, August 2022

7.11 Torbay & Devon Safeguarding Adults Partnership. Medicines Management. Guidance for organisations that provide care & support. October 2022.

9.1 https://www.gov.uk/government/publications/uk-covid-19-inquiry-terms-of-reference June 2022

9.5 Public Health Devon. Annual Report 2020-2021 https://www.devonhealthandwellbeing.org.uk/aphr/2020-21/

9.8 Newham Safeguarding Adults Board. https://www.newham.gov.uk/downloads/file/2750/newham-sar-in-rapid-time-peggy. January 2021

9.9 Barnet Safeguarding Adults Board. Safeguarding Adult Review, ‘Gabrielle’, 2022.

12. Appendix 1 - List of recommendations

	Recommendation	Agency	Timescale
1	Within 3 months of publication, the Royal Devon University Healthcare NHS Trust provides assurance to the Torbay & Devon Safeguarding Adults Partnership that the action plan developed following the amber investigation into Tony’s fall in Tiverton Hospital on the 18/12/2020 has been fully embedded into working practice across the Trust sites. This assurance should include examples as what action has been taken to reinforce or improve patient safety systems.	RDUH NHS Trust	3 months
2	The TDSAP seeks assurance from partners required to respond to patient safety incidents that communication with patients & families during single agency reportable patient safety incidents is based on using information from patients & families to improving patient safety.	TDSAP	6 months
3	The TDSAP works with the Torbay & Devon Health & Wellbeing Boards and the Devon Integrated Care System to understand the prevalence of injuries due to falls by those people deemed to be severely frail. This analysis to then inform whether current frailty provision across Devon & Torbay is commensurate with the risk of falls & fractures or to identify service provision gaps.	TDSAP Torbay & Devon HWB’s Devon ICS	6 months
4	The TDSAP disseminates both the Medicines Management guidance & the Somerset Safeguarding Adult Board practice briefing relating to ‘Mrs L’ to their provider sector partners via provider & primary care networks.	TDSAP	3 months
5	Within 6 months, Devon County Council Integrated Adult Social Care provides assurance to the Torbay & Devon Safeguarding Adults Partnership that changes to initial contact into their care system is realising the intended benefits of improving access to their care system, including quality of advice, timeliness, and needs of unpaid carers.	Devon Integrated ASC	6 months
6	The TDSAP as part of its planning cycle, considers how learning from the Covid-19 pandemic can improve the safeguarding of adults with care & support needs, including how it can be assured that partners contingency plans during periods of exceptional demand maintain the safeguarding of this cohort of vulnerable people.	TDSAP	6 months
7	The chair of the TDSAP starts a discussion amongst regional & national chairs as to how learning from safeguarding adult reviews can be collated & disseminated at a national level, whether that is through the national network engagement with The Department of Health & Social Care or the UK Covid19 inquiry.	TDSAP Chair	3 months

13. Appendix 2 - Terms of reference for review

 

Torbay & Devon Safeguarding Adults Partnership Terms of reference & methodology for Tony.

1.0 Background to review.

1.1This safeguarding adults review (SAR), commissioned by the Torbay & Devon Safeguarding Adults Partnership (TDSAP) surrounds the circumstances leading up to the death of Tony. Tony died on the 7th February 2021 whilst an in- patient in Derriford Hospital. Tony was aged 89 at the time of his death.

1.2 Prior to his death, Tony was known to a number of agencies including Devon County Council Integrated Adults Social Care, Mid Devon District Council, The Royal Devon & Exeter NHS Foundation Trust, Camplehaye Care Home, Tavistock & 2 GP surgeries.

1.3 The initial referral to the TDSAP was made by a DCC Adult Social Worker on the 26th April 2021. The TDSAP Safeguarding Adults Review Group (SARG) considered after requesting detailed information from relevant agencies (Appendix 2’s) that the referral met the pre-requisites for a mandatory safeguarding adults review.

1.4 Preliminary action by TDSAP.

TDSAP requested members of its SAR Core Group to identify those partner agencies who had a level of engagement with Tony that would enable an effective review. The following agencies were identified.

• Devon County Council – Integrated Adult Social Care
• Tiverton Hospital, Royal Devon University Healthcare NHS Foundation Trust
• Derriford Hospital, University Hospitals Plymouth NHS Trust
• Camplehaye Care Home, Tavistock (Avenscarehomes)
• Bow Surgery
• Abbey Surgery, Tavistock
• South West Ambulance Service Foundation Trust

1.5 All above agencies provided an appendix 2.

The purpose of the Appendix 2 is to gain an overview of events and changes in an adult’s life, including any relevant information regarding their wider family including any children they parent or care for.

1.6 Summary of relevant issues from Appendix 2’s & other documentation

• Tony’s main carer during the latter stages of his life was his wife, Anne.
• Prior to his initial hospitalisation to RDE Hospital on 22/11/2020 Tony had been assessed under The Care Act. However, any potential support had not been received prior to Tony being admitted to hospital. Admitted due to multiple falls causing injuries to shoulder & hip.
• Following his initial hospitalisation, Tony was transferred to Tiverton Hospital on 30/11/20 for ongoing rehabilitation. During this period, Tony contracted Covid19 and also fell & fractured his hip.
• Tony returned to RD&E for acute care but returned to Tiverton on 01/01/2020.
• Tony was subsequently transferred to Camplehaye Care Home, Tavistock for ongoing care, on 22/01/2021. Camplyhaye is a Residential Care Home.
• On 03/02/2021 Tony was admitted to Derriford Hospital due to dislocating his new prosthetic hip. On the 05/02/2021 Tony had emergency left girdlestone surgery.
• Tony sadly died at 8.45am on 07/02/2021.
• Following the fall in Tiverton Hospital causing a fractured hip, an amber investigation was carried out by a clinical nurse manager. Although the fall was deemed to be unavoidable, a number of recommendations were identified together with an action plan.
• An inquest hearing on the 21st September 2021 recorded ‘Accident’ as to the conclusion of the coroner, on the basis that following a fall at Camplyhaye Care Home on 3rd February 2021, Tony was admitted to Derriford Hospital for surgery to manipulate a hip dislocation. Tony subsequently deteriorated following surgery and developed pneumonia & sepsis. Both these and the initial hip disclosure were recorded as medical causes of death.

2.0 Methodology.

2.1 The TDSAP has developed a structured process for identifying the ‘best fit’ methodology for producing a review that maximises the learning from a tragic event such as the death of Tony. It must be noted that a review is more than a final report. The review process, including collating information, involvement of the family, engagement & consultation with both practitioners & managers and drawing from previous learning are equally as important as a final report.

2.2 The options as identified by TDSAP for the review process includes.

Significant Event Analysis or Multi Agency Case Audit (MACA): This approach brings together managers and / or practitioners to consider significant events within a case and together analyse what went well and what could have been done differently, producing a joint action plan with recommendations for learning and development.

A Themed Systems Review: The ‘systems’ model has been identified as a means of identifying which factors in the work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. A number of SARs with similar themes can be grouped together to review and identify consistent system learning. It is a collaborative model for case reviews – those directly involved in the case are centrally and actively involved in the analysis and development of recommendations.

A review using Individual Management Reviews to Analyse Performance: Individual Management Reviews (IMRs) are intended as a means of enabling organisations to reflect and critically analyse their involvement with key individuals in the case under consideration, identifying good practice, and that where systems, processes, individual and group practice could be enhanced. Individual Management Reviews can be used either as a tool of their own in a SAR or as part of a more detailed review.

A multi-agency Combined Chronology review: Developing a chronology of events is a useful way of achieving an overview of a case or situation and considering the areas for development or change. With a combined chronology, this perspective is greatly enhanced and enables us to identify not only gaps in service provision(s) or practice, and therefore areas for development, but also missed opportunities for communication between agencies.

A traditional SAR approach, using a Combined Chronology, Individual Management Reviews and a Review Panel: It maybe that the subgroup considers that the best way addresses a complex case if for the agencies concerned to participate in a review that follows the model of a traditional SAR.

2.3 Although 5 distinct methodologies have been adopted by TDSAP, a lead reviewer can adapt a review process that can take a number of elements from the above methodologies that will draw out the best available learning for individual agencies and/or partnership system to take forward.

2.4 Following an initial review of submitted Appendix 2’s & associated document provided to the lead reviewer, the proposed methodology for Tony’s review is as follows.

• Review of Appendix 2’s provided to the lead reviewer to identify any learning already identified, any action that has already been taken as a consequence of their involvement with Tony, & any recommendations identified by the agency. This element of the process will also, through an analysis of Appendix 2’s, identify any further requests to other agencies who may have relevant information to contribute to this review.
• Where there has been a service provided to Tony by a specific agency, a chronological review will be analysed to identify consistency of service, any best practice delivered over that time, or any improvements that could be made service e.g. continuity of staffing, timeliness of activity, supervision etc.
•  A review of any national or local policies, guidance, working practice that is relevant to minimise the harm or risk of harm posed to Tony.
•  Underpinning the above, the direct involvement of Tony’s family so that Tony’ s voice can be heard during this review, and the family’s perspective as to how agencies supported Tony both as individual agencies & as a partnership.

3.0 Terms of reference.

3.1 The primary function of this SAR will be to draw together the critical learning which identifies any systemic issues & learns lessons for the future and identifies any necessary action. It will also consider what the relevant agencies involved in the case both did well in mitigating risk of harm to Tony, but also what might have done differently that could have prevented harm/risk of harm.

3.2 From an initial review of the Appendix 2’s there appears to be 5 distinct phases of Tony’s care that is relevant to the overarching purpose of a SAR.

• Inter-agency working in relation to Tony 12 months prior to hospital admission on the 22/11/20. Tony suffered several co-morbidities and was vulnerable due to falls & chest infections. His wife Anne had made requests for Occupational Therapist in February 2020.  On the 2/11/20 a Care Act Assessment was completed, but although there was support for Tony, Tony was admitted to the RD&E on the 22/11/20 before a formal care package could be progressed.
• Inter-agency working, case coordination & decision-making regarding Tony’s discharge from Tiverton Hospital to Camplehayes Residential Care Home.
• Direct work & organisational features relating to Tony’s stay at Camplehaye Care Home.
• How did local & national policies from the Coronavirus pandemic impinge on the service provided to Tony & his family?
• How did agencies work together to identify & assess risk in relation to Tony’s main carer, his wife Anne?

3.3 Within the parameters set above the review will consider & seek to address.

• Understanding of the person: How well was Tony understood as an individual with his own needs & wishes. To what extent was this recorded/communicated?
• Are there any national or local working practices/guidance or policies that are relevant to Tony? How well were these implemented for him? Were the services available to Tony commensurate with risk & provided in a timely and sustainable way.
• Where agencies were unable to provide a service to Tony or felt they this required the services of another agency, how was this recorded, communicated & followed up?
• The review will seek to draw on previously published local & national SAR’s where similar harms/risk of harm were identified.
• What are the main issues identified for the way in which organisations work to safeguard and promote the welfare of high-risk individuals?
• Underpinning the above, the direct involvement of Tony’s family so that his voice can be heard during this review, and the family’s perspective as to how agencies supported Tony both as individual agencies & as a partnership.
• Recommendations will follow CLEAR principles.
  • Case for change.
  • Learning orientated.
  • Evidence based.
  • Assigning responsibility.
  • Review timeframe & resources required for change.

 

Report author

Keith Perkin

Lead Reviewer