Contents
1. Introduction
In March 2023 the Torbay and Devon Safeguarding Adults Partnership (TDSAP) received a Safeguarding Adults Review (SAR) referral from Devon Partnership Trust (DPT). The characteristics of the referral are recorded as self-neglect and was made in response to the death of William who was found deceased in his own property in December 2022. HM Coroner’s Officer recorded the cause of death as Hypothermia.
The TDSAP concluded that the referral met the mandatory s.44 Care Act 2014 duty to arrange for a SAR. The TDSAP must arrange for a SAR if an adult in its area dies as a result of abuse or neglect and there is a concern that partner agencies could have worked more effectively to protect the adult. [1]
SARs seek to establish what agencies and individuals involved may have done differently. The process is centred around identifying lessons that can be learned and applying those lessons to prevent similar harm in the future. Reviews should encourage honesty and transparency to ensure that the maximum value can be obtained to support effective recommendations and learning outcomes. SARs may also be used to explore examples of good practice where this is likely to identify lessons that can be applied to future cases. [2]
Best practice identifies that it is important that SARs build on rather than repeat findings and recommendations previously commissioned by the TDSAP [3]. In response, this SAR aimed to draw on available learning already identified from previous reviews relating to self-neglect commissioned by the TDSAP and evaluate what if anything has changed and where best practice barriers may remain.
This name of the individual subject to this review has been altered to William to protect their identity.
[1] Section 44 (1,2), Care Act 2014
[2] Care Act Statutory Guidance. Para 14.164, 14.168 and 14.169
[3] Briefing for SAB Chairs and Business Managers: Second Analysis of Safeguarding Adults Reviews. April 2024. LGA
2. The SAR process
2.1 The TDSAP appointed a Lead Reviewer to lead on the review [4]
2.2 The TDSAP received information from all the agencies involved from the 1st December 2020 until William’s death on the 15th December 2022. This information was made available to the Lead Reviewer at the beginning of the SAR process enabling the reviewer to identify key initial themes emerging from the information submitted. Some additional information was requested throughout the review process.
2.3 TDSAP organised a panel of members to ensure there is a formal record of the process undertaken to agree the Terms of Reference (TOR) for the review and ensure methodology and progression of the review was completed in a timely manner.
2.4 Practitioners are often best placed to identify change in systems and how barriers to best practice may be overcome. A learning review event was held and well attended by practitioners who knew William and had contact with him during the timeline of the review. The agreed methodology utilised for the learning event was an Appreciative Inquiry [5]. Building on previous self-neglect SAR activity commissioned by the TDSAP and the dissemination of learning review information, the aims of the Inquiry event where to explore practitioners experience of best practice and develop a shared vision of what further can be designed and achieved to support improved outcomes for people in circumstances of self-neglect.
2.5 William has one surviving brother who was invited to contribute to the review process. His brother subsequently declined this offer.
[4] Jon Anthony has worked for a number of years as the Head of Safeguarding Adults, Mental Capacity Act and Deprivation of Liberty Safeguards across an Integrated health and social care organisation. In addition, he is an Associate Director of Social Work and Professional Practice for Adult Social Care.
[5] Appreciative Inquiry in Safeguarding Adults Practice Tool 2015. RIPFA.
3. Terms of reference (TOR)
3.1 The TDSAP requested a reflective review. To look at what, if any, difference the learning from the Thematic SAR Self Neglect might have made in this case. Including, how information contained within the TDSAP Thematic SAR Self Neglect Practitioner Briefing distributed in February 2023 might have altered practice in this case.
3.2 The review will also look at good practices evidenced in this case and how the TDSAP can best develop and disseminate this. The evidence base of best practice for this review is derived from established research relating to self- neglect [6]
3.3 The review aims to build on previous learning review outcomes commissioned by the TDSAP and identify what can further be achieved to embed and enhance current practice.
3.4 The TDSAP is mindful of the benefit of hindsight but has identified the following issues to be addressed by the agencies contributing to the review. Some of these questions will not be relevant to all agencies, and, where that is the case, they should make that clear in their responses. The panel considered the following linked to the domain of best practice.
- Assessment of Risk Management Planning
- Consideration of Mental Capacity and Executive Function
- Historical Context
- Relationship Based Practice
- Awareness by Health Professionals of Feigned Compliance by an Individual Possibly Self-Neglecting
- Bereavement Support
- Trauma
3.5 The review should also capture wider learning in the context of inter-agency working, organisational and governance systems.
[6] Self-Neglect and Safeguarding Adults Reviews: Towards a Model of Understanding Facilitators and Barriers to Best Practice. Preston-Shoot M. 2018. Accessed here 22nd July 2024
4. William
William was born in Wiltshire and was 79yrs of age at the time of his death. He never married or had children and was described as a quiet reserved young man who often chose to spend time on his own. He was popular with others and enjoyed reading or watching films. From his early to mid-thirties, he returned to live with his parents and worked as an accountant with a company linked to a car manufacturer. He moved to Devon at the same time of his retiring parents when he was in his mid-forties and purchased his flat. He was part of his local community and worked as a postman. He would often talk about his time as a postman which he was very proud of. His father passed away in 1987 and his mother passed away in 1994. His surviving family described to practitioners that his mother would do everything for him and William would reaffirm this.
Following the death of his mother William immediately started to withdraw. He rarely answered his phone and had little communication thereafter with his surviving brothers, but they did keep in minimal contact. His brothers visited him as they were worried about lack of contact approximately 14 years ago and they were shocked by the state of his property. It was dirty and papers were piled halfway up walls.
Practitioners described William’s flat as having newspaper all over the floor, some of which dated back to 2008, plastic cartons would also be stacked in a central place. When speaking about his home environment William would give responses like “I don’t know how it gets like this”, “I clean it up and then it just gets messy again”.
All his personal paperwork and books were stacked neatly. William loved to read and he did not want to get rid of anything he had already read or might want to read in the future. Things that were important to William appeared well organised. On the last home visit by Devon and Somerset Fire and Rescue Service (DSFRS) it was noted that there was water pooling on the floor. When asked about it, he gave a nonchalant response as if he was avoiding it or hoping it would fix itself. The fire service deemed his home to be a high fire risk from 1st July 2021. A smoke alarm was provided and a safeguarding concern was raised.
The clothes that he wore were extremely worn and threadbare most likely dating back to when his mother was alive. This included a hat he would wear that had worn down to just a rim, torn trousers and no soles on shoes. He also developed a large scrotal hernia which was inoperable and would often be visible due to his torn trousers which would not afford protection. There is one record of William being asked to leave a community environment due to his appearance.
On one occasion, William said a stranger put money in his hand thinking he was homeless. William appeared genuinely surprised by this and could not understand why someone may have thought this. William was quite a wealthy man, so his physical appearance was not dictated by money. He would spend up to £600 a month eating out in local café’s saying he did this to support local businesses.
William consistently expressed a reluctance to engage with professionals or consider offers of care and support saying he was fine and well fed as he ate out. However, throughout the timeline of this report, concerns from people within his community were raised. These came from a genuine concern for his welfare where he was described as a very ‘nice and compliant person’. One community report for example, highlighted that William would regularly cause public disturbances at night from his property balcony, but the concern contact was made from a welfare stance rather than one which would have flagged a different response from Devon and Cornwall Police (DCP).
One of William’s brothers passed away in November 2022 shortly before William’s death. His surviving brother could not get hold of William and through social media he received information from the local community that he had been seen looking really unwell, scruffy in appearance and his movements were described as ‘shuffly’.
After his death his brother visited his property and described being ‘truly shocked’ by the state of the property. The rooms were piled high with magazines and papers, there was dust and cobwebs everywhere and a bath was brim full of milk cartons and cans. There was no bed as such, just a mattress and a sheet.
5. The Appreciative Inquiry – process and key learning outcomes
5.1 The 4 stages of an Appreciative Inquiry process were applied to this event through the lens of William with the aim of identifying;
- What if any difference the learning from the Thematic SAR Self Neglect might have made in this case.
- Identify what can further be achieved to embed and enhance current practice.
5.2 The first stage of an Appreciative Inquiry is aimed at identifying what is working well (the discovery phase), the second phase examines what is the best we can achieve, thirdly there is a focus on developing these practice examples and ideas and finally designing a plan to implement them [7].
5.3 The third and fourth stages of the Inquiry are captured in the recommendations narrative of this review.
5.4 The inquiry was attended by practitioners who had engaged with William and some line managers. Representatives attended from
- Devon and Cornwall Police (DCP)
- Devon and Somerset Fire and Rescue Service (DSFRS)
- Devon County Council Integrated Adult Social Care Services (DCC)
- Devon Partnership Trust (DPT)
- General Practitioner (GP)
5.5 The TDSAP Thematic SAR Self Neglect Practitioner Briefing distributed in February 2023.
5.5.1 One of the key terms of reference for this review is to look at what, if any, difference the learning from the Thematic SAR Self Neglect might have made in this case. Including how information contained within the practitioner briefing distributed in 2023 might have altered practice.
5.5.2 Prior to the Appreciative Inquiry, the reviewer was able to meet with all but one attendee as part of the planning and preparation for the event. Within this process it was apparent that all practitioners were either not aware of the briefing or could not recall key areas of learning. This has also impacted on the ability to provide a wider analysis of this TOR.
5.5.3 Whilst the sample who fed-back awareness is very small, It is essential that the TDSAP partners consider the effectiveness of their distribution of the Thematic SAR Self Neglect Practitioner Briefing and its true impact. A key recommendation is that this needs to be considered as a system wide issue given the range of attendees at the Appreciative Inquiry. The reviewer is aware that the briefing has been circulated by the TDSAP, but it is strongly recommended that the partners consider utilising a wider range of internal team skill sets and resources such as communication, digital and media teams to maximise the opportunities to sustainably disseminate SAR publications. (Learning Recommendation 1)
5.5.4 The LGA Analysis of Safeguarding Adults Reviews (2024) highlights that out of 652 reports during April 2019 and March 2023 self-neglect as the most frequent type of abuse and neglect, being present in 60% of cases [8]. This follows a similar pattern reported in the LGA first analysis between April 2017 and March 2019 [9] in which self- neglect was the highest, featuring in 45% of reviews. This would indicate that despite numerous evidence-based research and SAR publications there is an opportunity nationally that the national network for chairs of the safeguarding adult boards and the LGA, consider how they can further maximise the dissemination of national learning review information, utilising resources such as social media, visual media, apps and info-graphic methods. The rationale being that sharing best practice examples and disseminate knowledge and learning between boards is stated with the networks terms of reference.
5.5.5 It is recommended that the TDSAP Chair raise this recommendation with the current Chair of the National Safeguarding Adults Boards network (Learning Recommendation 2)
5.5.6 The narrative below is linked to the learning review event and the four stages of an Appreciative Inquiry. They are considered against the domains of direct practice, Interagency working, organisational factors and governance.
5.6 What is working well (including what worked well in support of William)
5.6.1 Relationship Based Practice
5.6.2 Practitioners were able to articulate who William was throughout the learning event, giving good examples of conversations which were built on relationship- based principles of engaging, listening and building rapport. Practitioners were able to reflect on who William was, his likes and dislikes, what he had described about his relationship with his mother and his views of how he was managing independently. Whilst William did not wish to engage in adult social care intervention, he did not disengage and this allowed practitioners to retain contact with him when concerns were reported. William was often difficult to contact, so creative methods were required. He would often miss appointments but could be found out and about when he would be happy to take a practitioner back to his home. Understanding William’s experience of self-neglect was a consistent reflective theme. Practitioners gained a perspective of what strengths William had and accepted that William’s views on his appearance and his home environment did not conform with a social normality. Following the death of William’s brother in November 2022, DCC also facilitated a contact with William’s surviving brother, ensuring that William’s surviving relative was aware of the emerging concerns and risks to William.
5.6.3 Historical Context
5.6.4 The historical context of William as a person and his situation was therefore well known and insights into his life, his views and preferences were highlighted by practitioners. This went beyond talking direct to William, for example on occasion there had been contact with a brother and neighbours were also spoken to, providing valuable insight and information to evaluate risk.
5.6.5 Risk Assessment – the balance of the duty of care vs right to self- determination.
5.6.6 William’s own knowledge and understanding about his life and well-being was central to decision making. William did not see himself as at risk of harm and the right to self-determination was emphasised vs. the obligation to exercise a reasonable level of care. Whilst the timeline of this review covered the 2 years prior to his death, the appearance of William and his home environment where similar as far back as 13 years. Welfare concerns for example were reported in 2016. William’s refusal to accept support was therefore a longstanding position.
5.6.7 Attendees described keeping William on their radar. For example, a handover from a Police colleague to the Police Community Support Officer and from the adult social care worker to her manager when she left the organisation. It was also evident that the wider community provided a safety net for William and a willingness to report concerns from a place of genuine concern for his welfare.
5.6.8 Information sharing and Interagency Working
5.6.9 Many examples were given of information sharing when concerns were raised and coordinated activity. These were primarily between DSFRS, DCC, DCP and GP Practice and resulted in some joint home visits. In October 2020 for example, adult social care contact to William’s GP practice, identified that the GP practice had received a notification from North Devon District Hospital about William’s hernia which led to reminders to William to attend the appointment and then confirmation that he did attend with feedback of outcomes. On another occasion, a welfare concern from a member of public in 2021 resulted in a timely joint home visit between the DCC adult social care practitioner and GP and this also considered mental capacity. This then led to information sharing with DSFRS who agreed to a joint visit also.
5.7 What is the best we can achieve?
5.7.1 Interagency working
5.7.1 A sustainable method to share information of how services operate internally, how best to link with them, formally and informally and threshold for referrals would support more effective communication, case coordination and cross agency working. In William’s circumstance a key referral may have been accepted by DPT rather than declined if the role of the service and expectancies on referral information was better understood.
The DPT North Devon Locality Clinical Team Manager and equivalent local adult social care Community Service Manager agreed to establish regular informal meetings. The purpose of these meetings will be to promote positive inter- agency working, as well as ensure there are opportunities to discuss emerging concerns relating to people in circumstances of self-neglect and with other high- risk vulnerability. (Learning Recommendation 5)
It is recommended that other local services managers consider replicating this approach. The opportunity to consider how networks with a wide range of relevant stakeholders is maintained locally is also recommended and introduced. (Learning Recommendation 5)
5.7.2 Whilst the TDSAP’s proposals for multi-agency risk management meeting processes will consider high risk vulnerability, the role of regular multi-disciplinary case discussion meetings should be embedded across all operational teams as standard practice, thus providing the opportunity to draw on other practitioner and services experiential knowledge. Avoiding silo working by extending these discussions beyond single-agency activity, such as mental health and other relevant health and social care professionals would also strengthen the opportunities for cross agency coordination, risk management and appropriate information sharing at an early point. In William’s situation, if this was available the role of local DPT services for example may have been better understood and timely in response to a decline in William’s well-being. Cross agency preventative action may have been more effective. A reliance on email contacts would also be reduced resulting in better more streamlined communication across services.
The opportunity to better understand other organisations pressures and priorities and rationale for decision making would also be strengthened, possibly leading to other options being explored or result in effective escalation.
Beyond the role and purpose of Multi-Agency Risk Management Meeting (MARMM) protocols, agencies should consider having regular multi-agency risk management meeting arrangements to discuss preventative action to manage escalating risk. Meetings should be conducted taking into consideration the information sharing protocol published by the TDSAP [10] (Learning Recommendation 5)
5.7.3 Balance of the duty of care vs right to self-determination. Including in the context of Mental Capacity or Executive Functioning.
5.7.4 The Reviewer highlighted that the TDSAP recently approved Multi-Agency Risk Management Meeting (MARMM) guidance as a framework to respond to concerns about people with multiple complex needs. The guidance was seen as a positive framework to support individuals and if this had been enacted for William, it may have promoted greater engagement in the right moments in response to William’s circumstances.
5.7.5 A key discussion related to a critical period in late June 2022 to August 2022 and then up until William’s death, when welfare concern reports were received by DCC from DCP, DSFRS and members of the public. This is further discussed in the theme analysis at para 6. William had been managing and declining intervention for in excess of a decade.
5.7.6 But there was a tipping point from which practitioners considered more risk assessment activity should have been undertaken to seek clarity on this matter. Within a home visit on the 19th July 2022, reason to doubt mental capacity is recorded by DCC due to William’s repetitive responses. Reason to doubt mental capacity is observed again within a home visit on the 31st August 2022 by DCC a practitioner and the GP, who considered William lacked mental capacity to understand the risks to his safety due to his living conditions and clothing. Neither event resulted in a formal mental capacity act assessment.
5.7.7 The TDSAP Practitioner Briefing distributed in February 2023 highlights both the risk of becoming accustomed to poor standards of hygiene and the need for proactive intervention responses to reluctance to engage. Adequate attention to the mental capacity act and possible loss of Executive Function was reflected as being critical to this process and of how to intervene.
5.7.8 Whilst these are essential components to any risk assessment and management process, this balance was seen as a primary consideration when engaging with people in circumstances of self-neglect.
5.7.9 Practitioners want to and need to be consistent and confident in their approach to ensure they are taking all reasonable steps in response to concerns and evidence defensible decision making.
The TDSAP should develop a bespoke resource dedicated to applying best practice principles on how in practice practitioners can make defensible decisions relating to the assessment of right to self determination vs. duty of care for people in circumstances of self-neglect. (Learning Recommendation 6)
5.7.10 The need to understand and be confident in exploring executive function i.e. their ability to attend to consequences of a decision.
A briefing which describes how in practice to best explore executive function would promote a more consistent and greater understanding of executive function. (Learning Recommendation 7)
5.8 Organisational
5.8.1 Practitioners highlighted that a system of crossover working between Older People’s Mental Health teams and generic adult social care services would provide greater opportunity to collaborate and work jointly to assess and manage risk. In William’s case this appeared to be a barrier to planning a response to emerging concerns about William’s well-being from August 2022 onwards.
DCC and DPT should seek feedback from their relevant adult social care and Older People’s Mental Health practitioners to reflect on and identify if greater collaboration opportunities exist. Questions to connect ideas and deeper insights such as ‘what’s missing from this picture so far’ and questions to create forward movement such as ‘what’s possible’ or ‘what would make the most difference’ should be asked to seek and implement opportunities for greater collaboration. Qualitative feedback from those with lived experience should also inform this process. (Learning Recommendation 8)
5.8.2 Practitioners considered what their individual organisations need to do to embed learning into practice? Practitioners were given the opportunity to respond anonymously via a live feedback questionnaire.
- Organisations need to ensure key SAR learning points are embedded within mandatory training.
- Ensure learning review information is a rolling agenda item in regular team meetings.
- Ensure that learning review information is a core agenda item in core group / governance meetings.
- Ensure there are other additional regular training opportunities or internal workshop opportunities to receive learning review information.
- Build effective relationships at a practice level with other services to consider learning review outcomes.
(Learning Recommendation 1 and 4)
5.8.3 As in William’s case, there are inevitably going to be occasions when staff move on to different roles meaning that re-allocation of caseloads involving people in circumstances of self-neglect need to be reallocated. The group reflected that best practice would dictate an effective handover to new staff as far as possible to retain oversight, information and establish new relationships. Case closure at the point of such transitions or delays in re-allocation should not be undertaken without a clear defensible rationale being considered and recorded.
If there is a need to handover allocation to a different practitioner, service managers and supervisors must not close or delay re-allocations relating to individuals in circumstances of self-neglect without a careful review of the assessment of risk and ensuring this is defensibly justified.
Planned handover should occur as far as possible for those in circumstances of self-neglect – to ensure there is maximum opportunity to retain ongoing relationships and forward movement. (Learning Recommendation 9)
5.8.4 In October 2021 DCC made enquiries with cleaning companies to support William. Approximately 10 days later one company emailed DCC to say they had no capacity to support at this time and would recontact when they did. There is no record of the company calling back thereafter. Whilst the impact and effectiveness of such an intervention would have been questionable given William’s circumstances, practitioners asked how unmet need is escalated to commissioners so that they can understand where the gaps in services exist and the impact these have on health and social care intervention.
For those in circumstances of self-neglect, organisations must ensure there are effective mechanisms for front line staff to escalate unmet need to local commissioners. Local commissioners must then ensure there are effective feedback processes to front line teams so they can understand what if anything is happening in response. (Learning Recommendation 10)
5.9 TDSAP Governance
5.9.1 The awareness of the Self Neglect Thematic SAR is discussed at para. 5.5 above.
5.9.2 How the TDSAP should disseminate learning review information. Similar to the above, practitioners were given the opportunity to respond anonymously via a live feedback questionnaire.
The TDSAP partners should consider its processes of disseminating learning review information as follows:
- Using social media and other media resources
- By raising the profile and awareness of the TDSAP website
- Via health and social care bulletins for all staff – example via TDSAP newsletter.
- By offering bespoke training / learning events accessible across the partnership.
- Ensuring that learning review information is cascaded back to teams directly engaged to reflect on practice and learning opportunities.
- TDSAP should host an Annual Safeguarding Adult Conference
(Learning Review Recommendations 1, 2 and 4)
5.9.3 Practitioners also considered how the TDSAP can further promote its public and practice information webpage. Similar responses were identified.
The TDSAP should promote its public website and practice information as follows:
- Via a regular newsletter.
- Use of different social media platforms to promote the work of the partnership.
(Learning Review Recommendations 1)
[7] Appreciative Inquiry in Safeguarding Adults Practice Toolkit (2015). RIPFA.
[8] Second National Analysis of Safeguarding Adult Reviews: April 2019-March 2023 (executive summary). LGA. 2024. Accessed here on 23rd July 2024.
[9] Analysis of Safeguarding Adult Reviews: April 2017 – March 2019. LGA. 2020. Accessed here on 23rd July 2024.
[10] TDSAP Information Sharing Protocol (2023)
6. Thematic review of information provided by agencies – key themes in addition to those identified
6.1 Information of each agencies engagement with William was obtained from organisations between December 2020 and December 2022. The analysis provides an insight into responses from:
- DCC Integrated Adult Social Care and Safeguarding Team Responses
- DCP
- DSFRS
- DPT
- William’s GP surgery
6.2 Referring to the TORs, the fact that practitioners were not aware of the Thematic SAR Self Neglect indicates little difference would have been made in response to William’s situation. However, an analysis of the information provided promotes an opportunity to highlight further best practice and additional opportunities for learning. The thematic analysis was considered against the relevant domains of direct practice, interagency working, organisational factors and governance.
6.3 Consideration of Mental Capacity and Executive Function
6.3.1 Analysis of information provided shows a clear tipping point on the 19th July 2022 at which the assessment of William’s mental capacity shifts from being capacitated to reason to doubt mental capacity. This is further reinforced within a joint visit between adult social care and the GP on the 31st August 2022 which results in an urgent referral being submitted by the GP to the DPT Older Persons Mental Health Team (OPMH) requesting a formal memory and capacity assessment. At this point the GP clearly states that William lacks the mental capacity to understand the risks he is putting himself under due to living conditions and state of clothing.
6.3.2 With effect from 19th July 2022 onwards until William’s death on the 15th December 2022, no formal mental capacity act assessment was completed neither about specific decisions about self-care or acceptance of care and support. DCC in particular were raising concerns relating to capacity to DPT, but no capacity assessment was completed.
6.4 Executive Function
6.4.1 Whilst there is reference to mental capacity within agency information, executive function, i.e. his ability to carry out decisions is not referenced. The possibility of whether William had a neurodiversity which impacted on William’s ability to process information, function or present behaviourally is also not explored. This may have also supported a balanced assessment of the right to self determination vs. duty of care throughout the period of intervention.
6.4.2 Conclusion: Similar to the self-neglect thematic SAR, mental capacity and executive function did not seek adequate attention. As practitioners reported no awareness of the thematic SAR practice briefing, the TDSAP should consider what if anything has changed as a consequence of the 2023 publication. Mental capacity and executive function is referenced in Appendix 3 of the self-neglect thematic SAR [11]. The TDSAP should consider utilising this published information as referenced in para. 5.7.10. of this review.
6.5 Health and Social Care Needs
6.5.1 There are approximately 16 recorded welfare concerns reported to DCC between 15th April 2021 to 1st December 2022. From the 19th July 2022 until William’s death on the 15th December 2022, there are only 4 direct contact visits with William. Additional attempts were made which were unsuccessful due to no responses.
6.5.2 There is a clear duty of care [12] towards individuals who are potentially unable to protect themselves and it is imperative that agencies work together in a timely way to ensure that all reasonable steps have been taken in response. Interventions and responses did not ensure all reasonable steps where being taken in a timely manner. For example, the urgent referral to DPT on the 1st September 2022 by the GP was first questioned as being appropriate by DPT on the 6th September 2022 with the GP and then via an email on the 12th September 2022 having not received a response, to the adult social care manager suggesting DCC consider available legal frameworks. On the 4th October DPT informed the GP that the referral had been closed. On the 24th October DCC then requested an update from DPT on the GP referral and where advised this had been declined.
6.5.3 On the 26th October DCC raised their concerns to DPT at a Manager level which proposed discussion at the North Devon Coastal link meeting. DPT then recorded a plan to discuss William’s case in a multi-agency team meeting. On the 1st December 2022 William was discussed at a complex case forum meeting. It was agreed that a joined up assessment between OPMH and adult social care would be undertaken but this did not happen before William’s death despite the concerns for his mental capacity.
6.5.4 The situation was compounded by organisational staffing challenges for both DPT and DCC. DCC wanted to allocate William to a Social Worker but did not have the resource to allocate, however the case was informally held by an adult social care practitioner during this period.
6.5.5 The joint assessment agreed by OPMH on the 1st December 2022 was delayed due to longer waiting lists for assessment, sickness from COVID in the team, care notes not being available and one staff member being re-deployed to an in-patient setting.
6.5.6 Conclusion: Agencies were talking to each other and information was known about escalating risk, reason to doubt mental capacity and unusual behaviour (shouting and standing naked by his window, banging on walls / swearing), but similar to those identified in the Thematic SAR Self Neglect Practitioner Briefing, there was no timely or clear coordinated interagency risk assessment and management process enacted from the 19th July 2022 forward.
6.6 Trauma / Bereavement Support
6.6.1 Throughout the timeline of this review, the influences that led to William’s journey into self-neglect perhaps could have been explored further and appeared to have been influenced by his mother’s death. His answers to concerns indicated he did not perceive himself as living in circumstances of self-neglect and he often described not understanding why people were raising concerns for his welfare. His surviving brother also described how William effectively cut off from the rest of the family following his mother’s death. When William was advised of his brother’s death in November 2022, during the crisis period and just a few weeks before his own death, he showed little interest of receiving this news.
6.6.2 Conclusion: Whilst practitioners worked with William from a relationship- based stance, the TDSAP should scope what opportunities currently arise to enable practitioners to promote trauma informed enquiries in practice and identify if these opportunities can be strengthened. (Learning Recommendation – as this is already an action captured within TDSAP SAR Eric this has not been included in the recommendations for this SAR)
6.7 Fire Safety
6.7.1 Information provided by DSFRS indicates one failed contact in November 2020 which was not followed up. At the next visit in July 2021 following contact from DCC, his property was deemed very high risk and there were concerns about his fridge which was making a lot of noise. In total 5 home safety visits occurred, the last being in partnership with DCC on the 1st December 2022 in which he was described as being oblivious to the concerns and risks associated with his living environment.
6.7.2 Conclusion: Although an initial attempted visit failed and was not followed up, the subsequent 5 home safety visits provide insight into the risks associated with William’s living environment. There were proactive contacts to adult social care services, including safeguarding concerns, diarised follow up visits and attempts to undertake joined up contacts. It is likely that DSFRS would have provided valuable information in relation to a formal assessment of William’s mental capacity and executive function if this had been undertaken.
6.8 Awareness by health professionals of feigned compliance by an individual possibly self-neglecting.
6.8.1 William had a large sacral hernia which was deemed to be inoperable. Within the Appreciative Inquiry it was noted that until the joint visit on the 31st August 2022 his GP medical records highlight no concern relating to mental capacity. When a request was made by adult social care for a joint visit to see William, this was immediately responded to and supported by the GP. The GP considered William to lack mental capacity and made an urgent referral to DPT for formal mental capacity act and mental health assessment. He also arranged for William to have bloods taken at the surgery and a plan was put in place for adult social care to visit him on the day and remind him of this, but unfortunately on the actual day, William had gone out and could not be found.
6.8.2 Conclusion: There is evidence from the response on the 31st August 2022 that the GP was responsive to a request for an urgent home visit and made a formal referral to DPT the following day. In the context of feigned compliance, William could not be located on the day he was due to have his bloods taken. This was fed-back to the GP surgery by adult social care, but it does not appear to have been replanned by the surgery or raised again by adult social care. Exploration of feigned compliance should be linked back to the overarching themes of mental capacity and executive function.
[11] TDSAP Thematic Safeguarding Adults Review – Self Neglect. February 2023 see here
[12] Care Act 2014, DHSC Care Act Statutory Guidance
7. Summary
7.1 William seemingly managed independently for many years in circumstances of self-neglect, most likely starting that journey following the death of his mother in 1994. There is a tipping point which arose mid 2022 in which escalating welfare concerns gave reason to doubt capacity relating to self-care or acceptance to offers of support. The Appreciative Inquiry and thematic analysis of IMR reports follows similar learning themes already identified in the Thematic SAR Self Neglect and practice briefing. Most significantly these relate to mental capacity, executive function, interagency meetings to develop shared planning in response to escalating risk and responding to an individual’s reluctance to engage. Organisational features relating to staffing and capacity also feature and may have been a factor in the capacity to respond in a timely manner. The Appreciative Inquiry was invaluable in considering additional learning relating to people in circumstances of self-neglect and these are referenced in the key recommendations section.
7.2 The primary conclusion is that over 12 months on from the publication of the thematic self-neglect SAR and practice briefing, front line practitioners did not have any awareness of this briefing meaning it cannot be certain that learning is being effectively disseminated. The partners of the TDSAP have a significant public resource at their disposal to enact public law duties as well as specialist communication, digital and media teams. The statutory partners should therefore draw on and utilise these resources and specialist teams to maximum effect to ultimately ensure better outcomes are achieved in response to circumstances of self-neglect.
7.3 Given that self-neglect has been consistently the highest type of abuse reported in SARs since 2017, increasing further in the recently reported LGA second national analysis, it is also recommended that consideration is given at a national level to utilising an extended range of digital media resources to cascade the most important messages from national analysis and research.
8. Key recommendations
8.1 The key recommendations link to the TORs. To identify how the TDSAP can best disseminate good practice and build on previous learning review outcomes commissioned by the TDSAP.
1. All TDSAP partners should engage with their internal communication teams and develop a sustainable communication strategy to effectively disseminate safeguarding adult review information. Partners should maximise digital media and other media resources available within their organisations. Considerations from this review include regular ‘safeguarding fundamentals’ webinars, newsletters, infographics and podcasts.
2. The LGA should consider what opportunities exist to utilise a wider range of digital and other media resources such as infographics to disseminate important messages from national SAR research and other safeguarding publications. The LGA is requested to feedback to the TDSAP the options explored and outcomes from this recommendation.
3. The TDSAP should consider hosting an annual safeguarding adults conference. The conference should support the dissemination of safeguarding adults review information, adult safeguarding research, publications and the priorities of the TDSAP.
4. The TDSAP partners should consider offering front line practitioners a wider opportunity to contribute to the creation and dissemination of learning review information. Offering continuing professional development and succession planning opportunities could be of value in enabling the TDSAP to embed best practice outcomes and complete learning review activity. This would also allow for greater connectivity between front line teams across the partnership.
5. This review reinforces recommendation 7 and 16 from the Thematic SAR Self Neglect to ensure that front line staff have systems to initiate effective multi-agency meetings to improve timely and whole system responses to individuals who self-neglect. DCC should seek qualitative feedback from front-line adult social care practitioners on the effectiveness of current arrangements and any opportunities for improvement.
6. DCC Integrated adult social care should evaluate what guidance it has to support staff in making defensible decisions relating to the assessment of right to self-determination vs. duty of care for people in circumstances of self-neglect. DCC should also survey the effectiveness of identified guidance in promoting best practice.
7. This review reinforces recommendation 5 of the Thematic SAR Self Neglect in the context of executive function and mental capacity practice for cases of self-neglect. The TDSAP Performance and Quality Assurance Group should confirm partners have undertaken audits in response to recommendation 5 and seek to understand the key learning outcomes and actions in response.
8. DCC and DPT should review their adult social care and Older People’s Mental Health Teams interface (including front line qualitative feedback) to identify if any opportunities for development and improvement exist within current arrangements.
9. DCC adult social care services should ensure managers and supervisors do not delay re-allocations relating to individuals in circumstances of self- neglect without a careful review of the assessment of risk and ensuring this is defensibly justified.
10. DCC adult social care should ensure there are mechanisms for front line staff and managers to escalate unmet need to local commissioners. Local Commissioners must then ensure there are effective feedback processes to adult social care front line managers so they can understand what if anything is happening in response. It is recommended this action is confirmed as being captured against the infra-structure of cooperation narrative referenced at para. 6.13.2 and recommendation 12 of the thematic SAR.
9. Appendix 1
Glossary of Acronyms
| DCC | Devon County Council |
| DCP | Devon and Cornwall Police |
| DHSC | Department of Health and Social Care |
| DSFRS | Devon and Somerset Fire and Rescue Service |
| DPT | Devon Partnership Trust |
| GP | General Practitioner |
| HM | His Majesty’s (Coroners Office) |
| IMR | Individual Management Review |
| LGA | Local Government Association |
| MARMM | Multi-Agency Risk Management Meeting |
| MDT | Multi-Disciplinary Team |
| OPMH | Older Persons Mental Health Team |
| RIPFA | Research in Practice for Adults |
| SAB | Safeguarding Adults Board |
| SAR | Safeguarding Adults Review |
| TDSAP | Torbay and Devon Safeguarding Adults Partnership |
| TOR | Terms of Reference |