SAR Adult C - learning briefing
Introduction
Sharing learning is a key priority of the East Sussex SAB. This includes developing strategic learning across agencies, boards and borders, learning from national best practice and SARs.
All staff and managers are encouraged to discuss the briefing and the key learning and reflection points at the end of the briefing. This ensures that the learning outcomes consolidate existing best practice and make improvements where needed.
Ask yourself:
- Can I make changes to my own practice?
- Do I need further support, supervision and training?
- Is there anything in my organisation that needs to change so that it can support best practice?
If you work with vulnerable adults in East Sussex, there may be additional specific actions and recommendations for your agency and your role.
This briefing summarises the key findings and actions for the SAB in response to this SAR.
Read the full Adult C SAR report, a response by the Board and a family statement.
Background
The East Sussex Safeguarding Adults Board (SAB) published the findings of a Safeguarding Adults Review (SAR) after the death of a 41-year-old woman, who is referred to in the report as Adult C.
Adult C was found dead by a friend on 31st December 2017. Whilst the cause of Adult C’s death was mixed drug toxicity, Adult C had experienced domestic violence and abuse on many occasions and at times she reported to feel suicidal.
There was a complex interplay of many other factors in Adult C’s life, including:
- Significant levels of domestic violence and coercive control
- Poor mental health, including a history of depression and patterns of self-harm
- Drug and alcohol dependency
- Involvement in criminal behaviour leading to a short-term prison sentence in August 2017
- Periods of street homelessness and barriers in accessing housing provision.
In addition, alternative care arrangements were in place for Adult C’s two children. Whilst Adult C had limited contact with them in the last couple of years of her life, she had spoken of her desire to reinstate more regular contact.
This SAR was led by Dr Sheila Fish from the Social Care Institute for Excellence (SCIE) and Alison Ridley an independent reviewer.
It focused on the last twelve months of Adult C’s life, a period which reflected an escalation in the domestic violence and coercion and control that she was experiencing.
Key findings
Finding 1 - accommodation
Situation
There is currently no accommodation readily available for women with the combination of needs related to chronic trauma, drug and alcohol abuse, homelessness and domestic violence and abuse.
Women wishing to remain within a couple are even less well served in terms of accommodation. This leaves practitioners having to rely on perseverance and luck to access viable accommodation.
SAR Adult C
Safe accommodation is a fundamental need for women with multiple complex needs and securing accommodation was central to Adult C’s safety plans.
Yet the complex interplay of Adult C’s needs meant that she experienced a range of barriers in accessing accommodation and standard options were not viable. This was despite the dedicated and persistent efforts of some frontline practitioners and the review commended this good practice.
Finding 2 - joined up services
Situation
Current service set ups locally are not joined up or tailored to the needs of a small cohort of women. These struggle with a combination of needs related to chronic trauma, drug and alcohol dependencies, homelessness and domestic violence and abuse.
This leaves some of the most vulnerable women either:
- excluded from services altogether based on eligibility criteria, or
- unable to access them because of the lack of proactive, flexible and intensive outreach support.
SAR Adult C
The review highlighted the challenges faced by services in trying to provide an effective joined up response working with women with multiple complex needs who have experienced significant trauma.
There are limited multi-agency mechanisms to:
- bring together staff across agencies to plan and review their work on cases considered high risk
- engage all relevant agencies in collective working to develop a ‘team around the adult’.
The review also highlighted the challenges when working with adults whose needs cross statutory frameworks and who may fall just below eligibility criteria. There may be a lack of a coordinated response and no lead agency.
Finding 3 - protocol
Situation
There is not currently an established multi-agency protocol or supporting tools for the proactive collection of third-party evidence of patterns of domestic violence and abuse.
This leaves police responding reactively to incidents of domestic violence and abuse and struggling to gather viable third-party evidence. It also leaves the voluntary sector frustrated at inaction against known perpetrators.
SAR Adult C
The review highlighted the challenges faced by practitioners in gathering, recording and sharing information in relation to domestic violence and abuse. It covers how this information:
- can be used most effectively in Multi-Agency Risk Assessment Conference (MARAC) meetings, and
- may be converted into evidence that may be used more effectively within police prosecutions.
The agencies working with Adult C held lots of information about the concerns relating to the abuse she was experiencing. But overall, there were gaps in information sharing across different agencies.
This meant that there was not a holistic picture of the escalation in domestic violence that Adult C was experiencing. At times incidents of domestic violence were approached as separate entities.
The review also reflected how practitioners can lack confidence to report incidents of domestic violence when an adult does not give explicit consent.
Finding 4 - out of area prison placements
Situation
Women who are given short custodial sentences are often placed out of their area of residence. This creates barriers for services in not being able to maintain active or direct contact with the adult. There is also insufficient time for any meaningful work to be carried out in terms of in-reach services into prisons.
SAR Adult C
For Adult C this compounded her risks. She was released from prison no longer being willing to engage in a residential detox placement. Also, no accommodation options had been put into place.
Actions for the SAB
The SAB is creating an action plan to take forward learning from this review and make improvements to services. Areas of development will include:
- Contributions towards the new joint strategy for specialist domestic violence services. This will mean accommodation and support services are more joined up. They will better support adults with multiple complex needs who are experiencing domestic abuse and coercion and control.
- The development of a multi-agency risk management framework. This will guide staff on working with adults where there is ongoing risk, but the circumstances may sit outside the statutory safeguarding framework or service eligibility thresholds.
- The development of multi-agency guidance or tools to support them in capturing information in more creative and proactive ways to support evidence-led prosecutions.
- Making improvements to MARAC on:
- ensuring all relevant agencies are involved in meetings
- how third-party information can support protection planning more effectively.
- Reviewing and updating SAB multi-agency training around domestic violence and abuse, and coercion and control in the light of any new guidance or supporting tools that are produced.
Family perspective
SARs are important to improving safeguarding systems and practices, but also in highlighting individual human stories. They reveal the impact on adults and their families of experiences of abuse and neglect.
Adult C’s mother provided a statement, published with the Board response [LINK to Doc] of which some excerpts are included below:
- Domestic violence is the primary cause of what went wrong for my daughter and created a barrier for her seeking help and support.
- The agencies working with my daughter should have communicated and shared information about risks more effectively.
- As a family we feel frustrated at the language used by many agencies to describe my daughter as ‘chaotic’ or making ‘lifestyle choices’. Such an approach is victim blaming and does not take account of how circumstances affect the decisions people have to make to keep themselves safe when experiencing such significant and terrifying abuse.
Further reading and training
- Sussex Safeguarding Adults Policy and Procedures
- Sussex SAR Protocol
- Sussex Information sharing guide and protocol
- Research in Practice – Coercive Control
- Domestic abuse and sexual violence - guidance for professionals – Safe in East Sussex
- Multi-agency risk assessment conferences – Safe in East Sussex
- East Sussex Learning Portal (ESLP) | East Sussex County Council has courses on domestic violence and abuse, coercion and control.
