SAR Gwen and Ian - learning briefing
Background
This joint review looks into the deaths of a woman aged 95 and a man aged 67, known as Gwen and Ian for the review. The unrelated deaths shared similar circumstances and potential learning.
Gwen lived with her daughter and had little involvement with services. After a rapid decline in her physical health, she was admitted to hospital in October 2021 and died the next day.
Ian lived with his son and had little involvement with services. He had experienced a range of traumatic events. In September 2022, after a rapid decline in his mental and physical health, Ian was admitted to hospital. He died the following month.
The SAR identified several themes including:
- engagement with statutory services and agencies
- raising safeguarding concerns
- care and support needs and carer assessments
- risk management and safeguarding
- personalisation – Making Safeguarding Personal
- mental capacity.
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
The review highlighted:
Early intervention
The importance of enhancing protective factors by making timely referrals and recognising carer stress.
Thorough assessment
Further assessment may have led staff to consider self-neglect, risk management, social care assessment and safeguarding action.
Strong relationships
Building strong and trusting professional relationships help us to understand their experience.
Good practice
The review found evidence that professionals and agencies tried their best to help Gwen and Ian in a way that suited their individual needs. There were some notable examples of good practice.
- The GP and community nurses tried to connect with Gwen and her daughter in April and May 2018.
- South East Coast Ambulance (SECamb) paramedics responded quickly to support Gwen in October 2021. They sensitively involved her daughter in decision-making and in escalating the safeguarding adults concern.
- When Ian missed appointments, his GP visited him at home in April 2022 and referred him for a dementia assessment.
- In September 2022, a community psychiatric nurse (CPN) was proactive in addressing a referral for Ian that had not been processed.
- Practitioners had respectful and skilled discussions with Ian’s son.
Recommendations for the SAB
The review made six recommendations.
Engagement by agencies
Develop a specific learning briefing for primary care on:
- best practice recommendations
- self-neglect referrals
- carers assessment.
Risk management and safeguarding adults concerns
Review the pan-Sussex multi-agency self-neglect procedures. Adult Social Care and Health (ASCH) to consider an audit of:
- front door referral information
- screening
- recording of self-neglect referrals.
Make sure that all the relevant organizations are training their staff to follow the procedures. This training should focus on professional curiosity and active listening.
Needs and carers assessments
Ensure that the relevant GP practice and mental health memory assessment service have improved how they refer patients and follow up. Make sure the improvements are being used and are working.
Personalisation
SAB partners to review the leaflets they publish for service users, families and the public. Make sure there is clear information on who to contact if you have a concern about care and what will happen.
Promote the use of:
- trauma-informed approaches
- professional curiosity
- active listening
Key learning
Making referrals
The review found that for both Gwen and Ian there were missed opportunities to make safeguarding referrals which could have improved their wellbeing.
To prevent this in future, the three Sussex Safeguarding Adults Boards developed the Safeguarding adults thresholds guidance.
The guide supports professionals, partners, and providers to decide on whether to report a safeguarding concern for an adult with care and support needs.
It also helps differentiate between quality issues and safeguarding and provides alternative actions to consider.
The guidance follows Section 42 (1) and (2) of the Care Act 2014 which sets out the:
- criteria that must be considered in relation to raising a safeguarding concern
- decision that follows as to whether a safeguarding enquiry is triggered.
It follows The Care and Support (Eligibility Criteria) Regulations, 2014.
Involving and supporting carers
The review showed that Gwen and Ian relied on family carers to care for them and these family members were struggling.
It's clear that Ian's son had eligible needs as a carer, and it's likely he would have accepted help including respite care.
An unpaid carer is someone who looks after a family members, friend or neighbour. They might care for more than one person.
The people they support may have a disability, physical or mental ill health, be frail, or misuse substances. Anyone can become a carer at any age.
The Care Act 2014 and unpaid carers: A handy summary | Local Government Association
State of the County - Focus on East Sussex | East Sussex County Council shows that 9.9% of the population in East Sussex provides any form of unpaid care, compared to the national average of 8.8%.
When should you consider a carer’s assessment?
If an adult looks after an adult who couldn’t manage without their help, they have a right to have their own needs assessed.
A carer’s assessment looks at:
- The care they provide and how this affects their life.
- Ways they can access support and what they would like to achieve.
- Their strengths and capabilities.
- Types of support available to them in the community.
Self-neglect
Before Gwen went into hospital, paramedics noticed that she was malnourished and had physical signs of self-neglect. Her home was also neglected. It was similar in Ian's case. Paramedics recorded concerns with self-neglect and increasing care needs, with no care package in place.
The Care Act 2014 Statutory Guidance provides the following definition: “Self-neglect covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding”.
Self-neglect is often defined across three domains:
- Neglect of self and lack of self-care.
- Neglect of the environment.
- Refusal to accept help and support.
The Social Care Institute for Excellence have produced general pointers for an effective approach: Self-neglect: At a glance | SCIE
- Multi-agency: work with partners to ensure the right approach for each individual.
- Person-centred: listen to the person and respect their views and perspectives of the individual, working towards outcomes they want.
- Acceptance: good risk management, not behavioural change, may be the best achievable outcome.
- Analytical: identifying underlying causes to help address the issue.
- Patience and time: short interventions are unlikely to be successful, practitioners should take a long-term approach.
- Always go back: regular, encouraging engagement and gentle persistence may help with progress and risk management.
The Sussex multi-agency procedures to support adults who self-neglect stress the importance of a person-centred and compassionate approach. This includes building a rapport and trust over time and gaining understanding of the complex causes of self-neglect.
Further reading and resources
- Sussex self-neglect practice guidance | Sussex Safeguarding Adults
- Sussex information sharing guide and protocol
- Safeguarding adults thresholds guidance
- Sussex SAR protocol
Training and development
East Sussex Learning Portal | East Sussex County Council offers multi-agency safeguarding courses, including self-neglect.
