SAR Donna - learning briefing
Background
Safeguarding Adult Review (SAR) Donna reviews the circumstances that led to the death of 41-year-old women, referred to in this review as ‘Donna’.
Donna was cared for by her daughter. She sadly died at home in 2021 from sudden unexplained death in alcohol misuse.
The SAR identified a number of themes including:
- Alcohol misuse and self-neglect
- Mental capacity assessment in relation to alcohol misuse
- Multi-agency response to risk management and joint working
- Consideration of the needs of a young carer
- Professional curiosity about domestic abuse and neglect
- The use of family support networks
- The impact of Covid-19 on service provision and awareness of self-neglect
- The interface between physical and mental health needs and substance misuse
We encourage all staff and managers to discuss and share the briefing. This helps embed the learning to improve our best practice and develop where needed.
Key findings
- Lack of co-ordinated, multi-agency response to Donna’s needs and risks
- Opportunities to initiate safeguarding enquiries were not taken
- No clinical mental health service referral for the assessment and treatment of Donna - although Donna’s mental capacity was correctly assumed under the Mental Capacity Act, further action could have been considered
- Lack of creativity in seeking support for Donna from family members
- Trauma-informed practice, exploring Donna’s life experiences was not evident
- Under reporting of personal consumption of alcohol
Good practice
- The local substance misuse service and their volunteers provided regular support to Donna.
- Aids from the Sensory Impairment Team helped to support Donna's sight loss.
- The East Sussex Fire and Rescue Service provided fire safety advice and aids within the home.
- Police and Ambulance staff recognised Donna’s self-neglect and the impact it was having on her family.
- Children’s Services provided counselling for Donna’s daughter. They supported her beyond the age of 18 in her transition to adulthood and living independently.
Key learning
Alcohol misuse and self-neglect
Alcohol misuse is a form of self-neglect when it starts to impact an individual’s health, mental health, wellbeing, family relationships and the safety of themselves and others.
If you think someone is underreporting their alcohol usage, try to talk to them about the effect of the alcohol. Ask whether they can recall events and appointments. Consider providing them with a breathalyser for personal use to record an accurate measure of their alcohol intake.
- Have you considered raising a safeguarding concern when you believe someone is self-neglecting through alcohol misuse?
Management of risk for adults misusing substances
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Are you aware of and have you used the common characteristics of alcohol-related SARs from Alcohol Change’s analysis to help manage risk?
Alcohol dependency and mental capacity
- Are you familiar with the Mental Capacity act in relation to the effects of alcohol on capacity?
- Are you aware of the effect of misuse of alcohol on brain function?
Trauma informed practice
- How do you and your agency take a trauma-informed approach?
Further reading and resources
- SAR Donna report
- Mental capacity multi-agency policy and procedures
- Sussex safeguarding adults policy and procedures
- Sussex information sharing guide and protocol
- Sussex safeguarding adults thresholds guidance
- Reporting a Safeguarding Concern
- Sussex SAR Protocol
- Alcohol Related Brain Damage Network
- East Sussex Alcohol Harm Reduction Strategy
East Sussex Learning Portal (ESLP) | East Sussex County Council
The Learning Portal has multi-agency safeguarding courses, including on self-neglect, trauma-informed practice and Mental Capacity.
