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SAR Adult A - learning briefing

SAR Adult A - learning briefing

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Introduction

This briefing summarises the key findings and recommendations from the Adult A SAR.

All staff and managers are encouraged to discuss this briefing and the key learning and reflection points. This ensures that the learning outcomes are used to consolidate existing best practice and make improvements where required.

If you work with vulnerable adults in East Sussex, there may be additional specific actions and recommendations for your agency and your role.

Background

The Adult A SAR evaluates multi-agency responses to the death of a man aged 64 (Adult A). He was from Kent but was living in a care home with nursing in East Sussex, commissioned by NHS West Kent Clinical Commissioning Group (CCG).

Adult A died as a result of systemic sepsis, infection of his legs, diabetes and cirrhosis. He was subject to Deprivation of Liberty (DoL) in his best interests as he was deemed to lack mental capacity to decide where to live. There were concerns of self-neglect as he often refused care and treatment.

The review

SAR Adult A was led by independent reviewers Suzy Braye and Michael Preston-Shoot and examined the following areas:

How care placements were organised and reviewed.
How health and social care professionals worked together across geographical borders.
How Adult A was engaged with.
How mental capacity and Deprivation of Liberty were assessed.
How the interface between the Mental Capacity Act (MCA) and the Mental Health Act (MHA) were understood and applied by professionals.
How care and treatment plans were agreed and followed.

The review covered the period of 25 August 2015 from Mr A’s admission to Maidstone Hospital, until his death in the nursing home on 24 July 2016.

23 recommendations were accepted by the SAB following the review. A joint action plan with the Kent and Medway SAB is now in place to ensure learning outcomes are achieved and to try and avoid similar cases in the future.

East Sussex SAB is committed to taking the learning forward to safeguard adults and hopes the findings will inform policies and practice elsewhere in the UK.

Key findings

Finding 1: Placement

Difficulties finding somewhere where Mr A’s care and treatment could be managed started well before the period under review, while Mr A was living in Kent. The review identified a shortfall of placements suitable for people, like Mr A, who have highly complex needs.

SAR recommendations for the SAB

Promote the development of a database of specialist placements capable of managing people with complex needs and challenging forms of behaviour.
Promote work between relevant CCGs to address the commissioning and market-shaping gap on services for people with complex needs and challenging forms of behaviour.
Seek reassurance that commissioning processes are robust in identifying the degree to which recommended placements have the capacity and resources to meet an individual’s identified care and support needs.

Finding 2: Coordination and inter-agency communication

The unsuitable nature of the placement was compounded by a lack of proactive follow up by NHS West Kent CCG, and a resultant failure of case coordination. Challenges of working across borders and at a distance may have added to the difficulties.

On no occasion did all relevant agencies and professionals come together to agree a plan to intervene in Mr A’s best interests. Without strong leadership across the system, the efforts that individual agencies made to secure care and treatment for Mr A took place in isolation.

SAR recommendations for the SAB

These included that the SAB:

Seek reassurance regarding systems in place for notification and monitoring of out-of-county placements both where East Sussex is the placing organisation and the receiving organisation.
Undertake an audit of out-of-county placements to evaluate whether there are systemic patterns to be addressed.
Review complex case procedures. Ensure that all agencies are aware of procedures for multi-agency reviews of complex cases, so that:
- all available information is shared across the agencies involved
- all agencies have access to advice and guidance from legal practitioners
- all agencies agree and follow through on a multi-agency action plan.
For all care and nursing home residents, promote the use of one shared record held at the care home by all professionals involved. This is to ensure that all practitioners are aware of the key issues within the chronology of the case when visiting a resident.
Establish a task and finish group to review record keeping and information sharing between agencies. It should make proposals regarding the transfer of information, including reference to hospital discharge planning and admissions to care homes, and complex cases involving concerns about self-neglect and mental capacity.

Finding 3: Mental capacity

At most points at which capacity was assessed, Mr A was found to lack capacity to make decisions relating to his living situation and his care and treatment. One such assessment by a doctor at Maidstone Hospital resulted in a decision to place him in a nursing home in East Sussex. Afterwards, a decision was made to authorise the deprivation of his liberty to ensure that he remained there.

Paradoxically, Mr A’s refusal of care and treatment on a daily basis in the nursing home was respected by staff and endorsed at a best interests meeting in January 2016.

Best interests interventions using the protections of the Mental Capacity Act were not actively pursued. No consideration was given to referring Mr A’s case to the Court of Protection. A referral would have been entirely appropriate at various points during the final six months of his life.

SAR recommendations for the SAB

These included that the SAB:

Review the effectiveness of training in raising awareness and strengthening knowledge of the Mental Capacity Act 2005, referrals to the Office of the Public Guardian and the Court of Protection.
Conduct an audit of cases to evaluate the outcomes of best interests decision making. Particularly assessing multi-agency involvement and clarity about leadership responsibility.
Review guidance on mental capacity assessment to include a process for securing multidisciplinary capacity assessment in complex cases where multidisciplinary teams are responsible for decision making.
Review guidance for staff on working with those holding lasting power of attorney (LPA).

Finding 4: Interface between mental capacity, mental health and physical health

There were missed opportunities to engage proactively with Mr A’s mental health, despite recognition that it affected his ability to allow others to care for him.

No community mental health referral was made at the time of his discharge from hospital.
No referral was made during the early months of his home placement, nor following the best interests meeting in January 2016.

No assessment took place despite advice from a consultant psychiatrist. They advised considering an assessment of whether Mr A met the grounds for hospital admission under the Mental Health Act 1983. This could have facilitated his physical treatment.

This was not proactively followed up by the nursing home, GP or the psychiatrist. This was a significant omission. The impact of his mental health as a potential underlying cause of his refusal of care and treatment was not tested.

The interface between physical health, mental health and mental capacity is complex, and required more explicit interagency discussion than it received in Mr A’s case.

SAR recommendations for the SAB

Review guidance on legal options for intervening in self-neglect, with and without capacity. Include consideration of the interface between the:

Mental Health Act 1983
Mental Capacity Act 2005
Court of Protection
inherent jurisdiction.

Review with commissioners and providers of advocacy services measures to address shortfall in the number of available advocates.

Include paid relevant persons representatives and independent mental capacity advocates.
Monitor further developments in advocacy provision.

Finding 5: Safeguarding

The review showed that safeguarding processes were not effectively used in Mr A’s case.

A safeguarding referral was not made until the weekend he died. Safeguarding referrals could and should have been made at numerous earlier points by any of the people involved in his care and treatment.

SAR recommendations for the SAB

Produce briefings to promote and refresh safeguarding literacy in the context of the Care Act 2014. These should cover the:

referral pathways and thresholds for section 42 safeguarding enquiries
use of complex case procedures and multi-agency meetings in challenging cases
awareness of, and confidence in, understanding factors contributing to self-neglect.

Seek reassurance that practitioners and managers across agencies:

understand and use pathways for seeking advice from, and escalating concerns to, safeguarding leads within their own organisation
are able to use safeguarding referral pathways appropriately.

Finding 6: Involvement

Although Mr A was placed in a location to which he and his attorney were opposed, his consistent refusal of intervention was respected. This was despite the view that he lacked capacity to make that decision.

His wishes were allowed to determine the actions that professionals took (or omitted to take). This was instead of being one of a number of factors to be taken into account in determining his best interests.

To comply with best interests decision making requirements, a more nuanced balance of a range of factors, including the risk to his life, was required.

The person who held lasting power of attorney (LPA) on behalf of Mr A was known to find this role difficult. This was both because of the distance to Mr A’s placement and because she was struggling anyway to make decisions in his best interests.

Not all agencies were aware of her existence. No consideration appears to have been given to whether her difficulties should have been notified to the Office of the Public Guardian (which oversees the work of those holding LPA.

SAR recommendations for the SAB

These are covered under Findings 3 and 4.

Key learning points

We encourage managers to explore the learning points below in team meetings and supervision.

Do you know who to report to or seek advice from if you have a safeguarding concern about an adult you are working with?

Do you know how to escalate a concern?

Are you familiar with the arrangements in your service for sharing information with other agencies?

Do you understand how the Mental Health Act and the Mental Capacity Act can be used to ensure that adults with mental health needs can get the treatment they need?