Safeguarding adults reviews

Date of review

October 2023

Reviewer

Melba Gomes

Owner

Monuara Ullah, London Borough of Hounslow

Executive summary

This report has been anonymised to protect the confidentiality of the person who is the subject of the report and their family.

Mr. Q was a Black African man from Angola, who arrived in the UK via Portugal. He left Angola during civil unrest. He was not in touch with his sister who lived in Portugal or his brother and sister in Angola. He had no family in the UK. He lived in Hounslow for about 13 years. He worked in a warehouse packing dried fruit until his amputations in 2019. Being able to have control over his life was important to him. In his assessment of January 2020, following discharge after a below knee amputation he said

‘I want my health conditions to improve. I want to return to being independent and not dependent’

He was diagnosed with peripheral vascular disease (PVD), Type 2 diabetes with associated maculopathy, heart issues and hypertension.

PVD affects organs supplied by the affected blood vessel. The brain, and hands can be affected. Legs and feet are commonly most affected. The associated risks are amputation, poor wound healing, restricted mobility due to pain or discomfort, severe pain in extremities and stroke, to name a few. Diabetes adds complications to patients with this illness. To manage the illness, Mr. Q had to comply with medication, eat a low cholesterol and low sugar diet, manage his weight and to undertake physical activity.

Mr. Q was in St Mary’s Hospital (SMH) at the beginning of 2020, having had a below knee amputation in December 2019. Although, he had had previous amputations on both his feet, this was the first time he was left without a usable leg. It does not appear that a home visit was undertaken to ascertain whether it was suitable for him to return in view of this change in circumstance. He declined a Care Act assessment while in hospital in January 2020 and left the hospital without care, insisting to the hospital that his friends would support him.

If professionals were aware of his home environment, they will have known that Mr. Q. resided on the first floor and would have had to use stairs to access his room, to use the kitchen to make meals and to leave the house. A housemate became concerned for him and began to support him. The district nurses (DNs) who were visiting for wound management made a referral to Adult Social Care (ASC) in January 2020 for care provision. He was assessed that month and a care package was put in place to support him with meals, personal care, and domestic chores. Referrals to assess and support him to use the stairs were not requested. Support to enable him to leave the house was not considered. Mr. Q said that he needed assistance with his nutrition; this was not explored. During this assessment ASC concluded that his accommodation was neither suitable nor safe for him to live in. They made a request for adapted accommodation from a single provider, Hounslow Homes, where resource was scarce. Mr. Q did not move to alternative accommodation until 1st September 2020, before which time his health deteriorated and he became increasingly dependent on others to provide for his needs. He did not return to being independent. He was moved to extra care housing.

Mr. Q returned to SMH on 18th February 2020 and had a further amputation on the same leg. He was transferred to West Middlesex Hospital (WMH) on 11th March for rehabilitation.

On 13th March, he declined an Occupational Therapy (OT) assessment, and it is recorded that he had the capacity to make the decision. No further attempts were made to engage him in an OT assessment, although the notes state that he was observed being able to transfer to his wheelchair independently. On the same day plans were made for his discharge. The homelessness worker disagreed with the decision to discharge him home, and a request by ASC for further assessments to inform discharge were declined. The physiotherapist assessed him to be at his functional level, although there is no reference to how he would negotiate the stairs in his home. A home visit by therapists did not take place to determine suitability of the home to his needs. He was discharged on 17th March, on the basis that he had reached his pre-admission functionality. The objections and Mr. Q’s persistence that he should not be discharged were unresolved. Although the arrangements were temporary while alternative accommodation was sought, these remained his living conditions until September 2020.

It was 17th March. Hospitals were beginning to see the impact of COVID. This was an unprecedented event for everyone, especially hospitals. There was no template informed by past experience to advise services how they could manage their patients safely during this period.

Placements/rehabilitation or resources to improve his independence were not sourced.

Mr. Q was discharged without any health input despite his complex health conditions, and the associated high risks. He was known as a person that did not

comply with his treatment therefore the risks of serious ill-health, without monitoring, were increased.

A referral for removal of staples on his amputated leg, was not sent to the DNs. Mr. Q attended WMH on 25th March 2020 because of abdominal pain; this was the day the first set of staples were due to be removed. The opportunity to begin the removal of staples was missed. The staples were removed a month later in WMH. A safeguarding concern was raised due to the delay.

On 27th May the Integrated Community Response Service (ICRS) responded to a referral that Mr. Q was unable to shower. On visiting they found him suffering from abdominal and back pain, fatigued, and dehydrated, with low SATs. They arranged for him to attend hospital. This was the first of 3 attendances to WMH in 4 days for similar concerns, a common problem being abdominal pain. The response from the hospital to these attendances was to address the presenting issue and discharge him home. On the third occasion, ICRS rang the hospital to relay their concerns. On that occasion he was admitted for investigations.

Following his discharge on 4th June, ICRS assessed him under the Discharge to Assess (D2A) process, and created a comprehensive care plan to include medication, nutrition, diabetes management including medication, nutrition and carer training, and therapy, which on completion by mid-July, saw him physically well so that he did not need to attend A&E for the same reasons. The key intervention that addressed his abdominal pain was nutritional advice provided by the dietician, which was followed up by the Carer. No other agency explored nutrition with him or his Carer during the period of review.

By June, Mr. Q’s mental health was impacted by his continued physical ill-health, and he was diagnosed with a depressive disorder. He moved to an extra care facility on 1st September 2020. He was admitted to Chelsea and Westminster Hospital two weeks later with a gangrenous finger which had developed into an ulcer that had become necrotic. Mr. Q was transferred to SMH where he died on 2nd October 2020.

The request from the Hounslow Safeguarding Board was that the SAR explores how agencies in Hounslow worked together; whether decisions made were appropriate, robust, and timely and if communication between agencies was appropriate and effective

The approach to Mr. Q’s care, treatment and accommodation was superficial (skimmed the surface of the issue, without probing or curiosity), piecemeal (applying partial rather than comprehensive measures), and uncoordinated (not joined up).

Care was reviewed in April and a carers assessment was completed on 7th May by ASC. Care was adjusted in line with the findings from the assessments/reviews until the beginning of May. From May, Mr. Q’s health began to deteriorate, and towards the end of May he became totally dependent on others to provide for his care and to keep him safe. Further reviews were not carried out in response to changes in need and therefore, the need for more suitable accommodation where health monitoring, and

medication and nutrition management could take place, was not identified. ASC instigated the health interventions when Mr. Q began to become unwell in May but they did not monitor the situation. ASC were only included in discussions by health partners when they were required to affect an outcome such as safeguarding, care or accommodation and hence, did not have a full picture of Mr. Q’s deterioration during May and June.

• The urgency to discharge Mr. Q from WMH when medically fit in March 2020 to unsuitable accommodation as a temporary measure was preferred to keeping him in hospital while all partners worked together to source suitable accommodation where his health could continue to improve. ASC referred him to a single housing provider where resources are scarce. He did not move until September 2020. Mr. Q was discharged without health care support. Mr. Q suffered ill-health at home and his mental health was impacted; a circumstance that could have been avoided in an accommodation where he was supported by appropriately trained and experienced staff.
• Treatment in hospital was not holistic i.e. set within the context of his overall conditions and associated risks. The treatment and investigations focused on immediate concerns, with the aim to get him to a position where he was well enough to be discharged. Working proactively to consider all areas of health and care needs might have prevented continued ill-health and further hospital attendances.
• In the absence of sufficient health and care community provision, the responsibility for social care and health needs fell on his Carer. She was not trained to respond to or to manage his complex health conditions. It was assumed that she would provide health care even when it was noted that she had limited understanding. She
• worked 48 hours a week and provided care between work shifts. There was an over-reliance on the Carer to fill gaps left by health and social care.
• In June 2020 ICRS applied a coordinated approach (Discharge to Assess, known as D2A) to deal with his health needs which resulted in improvements to his health, and his quality of life. ICRS demonstrated excellent practice, however, it would have been beneficial if the process included ASC, who then could have been called to account on the timeliness of sourcing appropriate accommodation and this might have led to a change in accommodation sooner.
• Assumptions were made that Mr. Q had the capacity to make decisions regarding his treatment, and that he was making unwise choices. There are many occasions where his understanding is called into question. English was not his first language and where he objected to treatment or care, as result of which, he would have been at risk, an interpreter should have been used to check his understanding of the information provided. This may have assisted in determining whether there were concerns regarding his capacity to make a particular decision at that point in time. He appeared to confabulate at times, and this can be an indication of cognitive issues which may have been linked to PVD. There is an absence of any history about Mr. Q from before he came to the UK. Therefore, it is not known what traumas he may have encountered which also may have had a bearing on his presentation and decision making.
• Mr. Q was unrepresented/unbefriended and his objections to being discharged home in March and July were not explored. His voice was not
• heard. General advocacy or a befriender or hearing from services that knew him well such as District Nurses (DNs) will have helped to amplify his voice.
• Health and social care communicated on specific issues as needed. They should have been working together to support Mr. Q to achieve his goals of improving his health and returning to independence.

The key recommendations are as follows:

1. Arrangements should be agreed of how health partners (including hospitals) and adult social care will work in a proactive and integrated way to meet the needs of patients with long term/complex/high risk health conditions
2. For patients with complex/long term or high-risk conditions, a multiagency person-centered risk assessment (informed by robust care or health assessments and views of patient) should be completed and an integrated care plan agreed, with a care coordinator at the helm to monitor and ensure progress in a timely way, to respond to triggers of risk and arrange regular reviews. Practice guidance should be made available
3. Arrangements should be in place to ensure that unrepresented/ unbefriended patients are supported to be heard
4. Services should provide guidance and training to staff to work in a rights based person-centered way which entails knowing the person behind the illness, and seeking the patient’s views, wishes and feelings, using appropriate tools/methods to facilitate communication.
5. All agencies remind staff to undertake robust assessments to inform a patient’s care plan, which should be kept under review and adapted in line with changes and for complex patients, this information should feed into the multiagency risk assessment and care plan.
6. Appropriate checks should be carried out on the person’s understanding of the risks, and appropriate tools used to support understanding and to verify they are making capacitated decisions. An Audit of the application of the Principle 1 and 2 of the MCA is advised.
7. A reminder should be sent to all staff that ongoing education and discussions should take place with non-compliant patients to encourage engagement with the care plan,
8. Carers, if they agree to carry out the caring role, should be trained and assessed for suitability to carry out the roles and supported to carry out complex caring roles. They should be asked if they feel able to continue in the role if needs change. It is suggested that agencies review Carers Policy in line with this finding.
9. Communication/cultural barriers between hospital and community services and vice versa should be addressed and communication between health partners and adult social care should be improved to provide a seamless service to patients
10. Recording should be thorough, continuous and abbreviation and jargon free to enable a patient/client to read and understand their journey through the service.
11. Create Risk Assessment and Risk Management Guidance and Forms, and train staff to use these
12. Provide guidance and training and support to ensure the robust application of all above processes in practice.
13. Audit use of above processes and gauge patient and carer experience to inform refinement of processes.
14. All agencies should consider their practice in relation to this SAR and the findings from this SAR, and make improvements to prevent similar concerns arising in the future

Impact of COVID

COVID was an unprecedented event that resulted in changes to delivery of services in hospitals and in community health services. Services were configured and it is likely that not all eventualities were considered when planning for this event. Mr. Q missed out from receiving health care due to a lack of a preventative approach and the absence of a risk assessment of patients at high risk of harm which may have informed the need for oversight of these patients while health services were stretched.

Hospitals will have been concerned that Mr. Q, due to diabetes, was at risk of serious ill health if he contracted COVID and this may have informed their approach to discharge. However, there was a need to balance this risk against the pain that he was experiencing that resulted in frequent attendances to A&E. Dealing with the issues sooner, and in a robust way, may have improved health and independence and prevented further hospital attendances.

Over time new processes such as the D2A process was introduced. D2A supported comprehensive multiagency assessments in patients homes or in a residential setting , and this arrangement was instrumental to health improvement for Mr. Q. Unfortunately, by then, Mr. Q had deteriorated to a point from which he did not recover to pre-COVID levels, and he was, no longer, expected to regain his independence.