Safeguarding adults reviews

Date of review

May 2024

Reviewer

Melba Gomes

Owner

Monuara Ullah, London Borough of Hounslow

Executive summary

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

Mr. Z and Mrs. Z lived with their daughter J during the period of review. They had another daughter L who lived outside London. She was a regular visitor to the home of Mr. and Mrs. Z, and she was interested in their welfare. Both daughters had Lasting Power of Attorney for Mr. and Mrs. Z’s finances.

Mr. Z was diagnosed with dementia many years before the period of review, and he could not contribute to his assessments although he could participate in simple conversations. Mrs. Z was his main carer. Both parents were dependent on J to take them to their appointments, to shop and to collect/ administer their medication.

J was diagnosed with depression and anxiety. In 2018, L became concerned about her parents. She felt that her mother could not care for her father because of her own needs and that J was not coping with caring for their parents. L said that J was not administering medication properly. During 2018, the GP had several calls from the pharmacy to say that their medication was not collected. In early 2019, the GP also said that the parents were not being brought to their appointments at the surgery. In 2019, Mrs. Z was also diagnosed with dementia. She continued to be the carer for her husband. No concerns were raised about their presentation.

In July 2020 when COVID lockdown rules were relaxed L had the opportunity to go into the house. She found that there was no food and that both her parents had lost weight, the house was dirty, and they had not had medication since early in the year. She also said her mother’s dementia was ‘through the roof’. On assessing Mrs. Z, ASC (Adult Social Care) found that Mrs. Z could no longer provide all the care to her husband. It was agreed that she would do what she could, and J would support her with all other tasks. They refused care but J accepted support from Hestia to assist her with her own finances and outstanding housing issues. ASC closed the case.

The Mental Health service (WLT) visited Mr. and Mrs. Z. Their last direct contact with Mr. Z was in person in August 2020 and with Mrs. Z in November 2020 via telephone. They attempted to see Mrs. Z in February 2021, but J told them they could not come in as her father had a cold and due to risk from COVID. The district nurse visited on 17th February to take bloods and again they were turned away for the same reasons. The district nurses tried to arrange further visits which were cancelled. They notified the GP. The GP did not follow up. The GP visited on 27th April to give them COVID Vaccinations and did not get a response. The GP notified L who called the police. On entering the property, the police found Mr. and Mrs. Z deceased. The coroner could not give a cause of death for Mrs. Z due to the level of decomposition of her body. They said that Mr. Z died of natural causes. J was detained under the Mental Health Act, and no criminal action was brought against her. She has since died.

Findings

A focus on risks may have drawn attention to the impact of J’s mental health on the caring role.

• Other than the GP, no agency viewed J as a carer. There is no evidence that any other agency asked J what she did for her parents. There is evidence that ASC was informed about the extent of her role by the GP and by L.
• Agencies to varying degrees, failed to understand J’s mental health condition, its impact on her and how, in turn, it affected her caring role. All professionals could have shown some curiosity towards J’s situation and found out more about her, how her anxiety manifested itself and how she felt in herself. This could have informed what support she would have accepted to improve her mental health and what support she would need to continue to care for her parents or if she could care for her parents at all.
• The extensive evidence in the GP chronology of noncompliance with medication and missed appointments should have provided sufficient grounds to respond and highlight the risks earlier and ongoingly to partners. In the absence of a joined-up plan, the responsibility lay with the GP to lead the response to non-compliance with medication and missed appointments as these were health needs with risks attached. There is no evidence that consideration was given by GP to undertake home visits or to utilise community health services or to hold multidisciplinary meetings to address medication management and compliance with health appointments.
• WLT as experts in Mental health and associated risks were best suited and had the opportunity to explore J’s behaviours around missing appointments made for her mother and her own mental health concerns that she shared with them. They also could have approached risk to their patients in a wholistic way as per their risk management policies. This may have led to an improved risk assessment.
• Safeguarding referrals were not properly investigated where concerns were raised against J with regards risks to Mr. and Mrs. Z. Lack of reference to historical concerns by ASC in assessment and safeguarding processes concerning J’s ability to care for her parents, combined with inadequate gathering of information to support investigations/ assessments and lack of liaison with agencies to understand needs, and limited or no investigations/analysis or risk assessments of specific concerns that were raised, entailed that risks were not identified and therefore, mitigations could not be put in place
• Appropriate and thorough application of correct legislation i.e. Care Act Assessments/ carers assessments (ASC), Safeguarding (ASC) or application of Mental Capacity/ Best Interests (ASC and GP) will have provided direction in this case.

Processes for working with people who disengage from services

• As early as 2018, patterns of disengagement were apparent; it was difficult to get hold of members of the household by phone. This disengagement extended to them not opening the door to professionals. J also denied that letters were received. Mr. and Mrs. Z were not being brought to appointments.
• WLT had a process to visit disengaging patients who were at risk. All partners, if working together, could have proactively agreed a way forward to address patients not attending appointments, and not being seen, with each playing a part to keep the family safe.
• Due to the failure to identify the risks, agencies did not work together to manage risks, therefore there was no multiagency proactive plan to deal with their disengagement.

A Preventative Approach was available

• There were three vulnerable people in the family, all of whom were co-dependent and had needs. ASC, WLT, and the GP were the key agencies working with Mr. and Mrs. Z, but all partners worked in silo, reaching out to each other intermittently.
• The GP surgery was best placed as all patients were under their care to use the ‘Think Family’ approach to understand the family dynamics, the risks and the shortfall in meeting needs and to engage other agencies to support the functioning of the family unit, perhaps through a multidisciplinary care plan.
• All agencies should be alert to households where several people reside who are vulnerable, and consideration should be given to how agencies will work together and share information to support the wellbeing of all members of the household to prevent risks and safeguard them.

Recommendations

• Staff should apply correct legislative processes to clients/patients’ situations. To this end it is advised that staff receive the training to become legally literate.
• Effective and wholistic risk assessments are key to managing risk. Past risk is an indicator of future risk therefore historical information must be considered when deciding the outcome of a safeguarding concern. To this end it is recommended that agencies review their documentation to support staff to properly assess risk. Training is also advised.
• ASC staff should be trained on mental health conditions to be able to make proper enquiries/ carry out assessments/carers assessments with understanding of conditions
• A briefing is recommended for all agencies to support better information gathering and analysis, to inform evidence-based decisions
• All agencies should have a procedure to respond to risks in a timely way, including timely home visits and escalation processes, when patients/ clients disengage or do not comply with measures to maintain their well-being and keep them safe
• A multiagency procedure to work together on cases should be put in place. This procedure should cover households where all/several members of the household are vulnerable, and patients/clients who disengage from services, to name a couple. The purpose of the procedures is to prevent safeguarding as per the Care Act statutory guidance.
• GP surgery has new multi-disciplinary rearrangements to review cases of concern which can be extended to respond to concerns of non-compliance with health needs and risk; the arrangement should include GP home visiting to respond to risk.
• All agencies that currently do not have such a policy should have one such for occasions where people are dependent on others to bring them to appointments, and they are not brought. The GP surgery has this arrangement in place.
• ASC should provide guidance to staff about when patients need care but refuse care.
• Think Family/ Whole Family approaches provide a wholistic preventative approach to working with families to promote their well-being and preempt risks. It is recommended that the Board commission this type of training for all agencies.
• It is important to talk to the client/patient directly rather than get information via a 3rd party, to be assured that the person is safe. COVID has taught services various ways of keeping in touch with patients virtually when direct face to face contact cannot take place. This learning should be used to improve monitoring of patients.
• All agencies should make changes within their services in line with their own findings after reflecting on the findings from this SAR.