SAR Hannah - learning briefing
Background
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.
This review looks into the death of Hannah aged 48 years, who died in May 2022 as a result of a head injury. Before she died Hannah's alcohol use increased significantly. This led to serious health problems. Hannah was intoxicated when she fell.
Hannah lived with her husband and young boys at the time of her death. The children were being supported by the local authority Early Help team within Children’s Services. Hannah’s drinking significantly escalated during the COVID-19 period.
Hannah’s physical health started to deteriorate significantly in early 2020 with the first of many hospital admissions. Hannah returned to the country of her birth, where her family lived, at the start of the COVID-19 pandemic for a period of residential rehabilitation. This was unsuccessful and, according to a close friend, the cause of much shame and anxiety. After, she had multiple alcohol-related medical problems, several hospital admissions and two private residential detox periods in the UK.
Key findings
Self-neglect and the harm caused by alcohol
Hannah was not able to always engage consistently with services that were offered. Her health was so bad that a doctor had to tell her very clearly that she would die if she kept drinking.
Even though this was a very serious warning, no one recognised it as self-neglect and there was no action. Hannah didn't follow the advice or treatment, and she often missed important appointments. The services involved didn't recognize that she was neglecting herself.
People who are dependent on substances like alcohol often deny they have a problem and reject help. This was the case with Hannah. But if someone is neglecting themselves, you do not need their consent to raise a safeguarding concern.
Multi-agency approaches to management of risk
The times when Hannah was in hospital were good chances for a multi-agency meeting to discuss her situation and how they could help her.
Looking back, the review found three things that could have made these stays more effective, and these ideas could also have been used to help her outside of hospital:
- Recognising self-neglect and considering the procedure, which may have led to a safeguarding enquiry
- Holding a multi-agency meeting or discussion
- Working closer with hospital alcohol services to help Hannah when she was discharged and to stay sober.
Consideration of carers
- Children’s Services were involved as there were two children in the household. It may have been good practice to carry out a Care Act assessment for Hannah and a carers assessment for her husband at the same time.
- There was no carer's assessment but the impact on the children was considered several times. This led to targeted Early Help.
- It could have been helpful to take a whole family approach. This would involve children's services, a Care Act assessment for Hannah, and a carer assessment for her husband. This approach might have given a better understanding with a more coordinated plan and a shared assessment of the risks.
Trauma-informed practice and approaches
Hannah seemed unwilling to accept help from agencies or her loved ones. They said she felt a sense of shame and stigma. However, there was a chance to explore more of the background issues.
The Mental Capacity Act 2005 recognizes that people with alcohol-related problems may have fluctuating capacity, meaning their ability to make decisions can vary. This can be influenced by substance use. In Hannah's case, her age, background, and behaviour when she wasn't drinking might have led people to assume she had capacity, rather than assessing it.
There are a number of factors in Hannah’s case that significantly changed her role and identity, and together could have created a trauma informed response. Different agencies were aware of some of these factors at various times, but they weren't considered together as a whole.
Her family and friends mentioned that she seemed to have lost a part of herself, although they couldn't pinpoint the exact reason. This suggests that multiple issues, including bereavement and the loss of her mother, might have contributed to her situation.
Good practice and key learning
- There had been good engagement with Change Grow Live (substance misuse service provider). Hannah said she was drinking more alcohol and feeling more depressed and anxious.
- A GP face to face appointment was arranged to include the attendance of the Early Help worker to support Hannah in accessing services that she needed.
- The Early Help team had considered that Hannah may have lacked executive capacity. The team helped to arrange a GP appointment and decided to make a safeguarding adult referral.
- The children were offered a school place during COVID-19 because they were considered vulnerable at home. This was arranged by Hannah’s husband and the headteacher.
- East Sussex Fire and Rescue Service (ESFRS) made a children’s safeguarding referral. They visited the family home to assist with getting Hannah to hospital. This resulted in a family assessment and the offer of Early Help Services which began in January 2022. ESFRS also made an adult social care referral.
- The GP raised concerns with children’s social care about the impact of maternal alcohol use on the children.
Self-neglect with a focus on alcohol dependency
Approaches to self-neglect must be informed by a Making Safeguarding Personal approach. They need to consider each adult’s experience and history to understand what may lie behind the self-neglecting behaviour and lack of engagement with professional support.
There is not one overarching explanatory model for why adults may self-neglect. Instead, it is a complex interplay of factors, that is likely to be the result of previous trauma.
Alcohol Change have highlighted the following myths and misconceptions:
Myth one: When we saw her, she was very clear that she didn’t have a problem and didn’t want help, so there is nothing we can do.
Myth two: She is not vulnerable; she is choosing to live like this, or she likes living like this.
Myth three: He is not vulnerable / self-neglecting because he has mental capacity.
Myth four: He has capacity, there is nothing we can do.
What helps engage alcohol dependent adults with intervention and support?
- Develop an engagement plan – think through how you can keep the person engaged.
- Provide diet advice and guidance - simply drinking without food increases the risk of liver disease. In the long-term vitamin B1 (thiamine) deficiency can result in alcohol related brain damage. The risk of dehydration exists which causes confusion and lethargy.
- Consider family or carer involvement in care planning. In some cases, this can help improve engagement and increase the likelihood that a care plan will succeed.
- If needed, make a referral to local alcohol treatment/recovery services. Signposting is not enough!! Prepare for the initial meeting by identifying support, entering treatment can be an intimidating experience. A warm supported introduction can help people feel at ease with understanding their recovery options.
- Use motivational interviewing approaches and promote self-belief.
Legal framework
In the context of alcohol use, there is a lack of understanding of the relationship between alcohol misuse and self-neglect.
There is often a perception that a person cannot be vulnerable or self-neglecting if they have capacity. If the person is assumed to have capacity, then the way they live their life is “choice”.
Perceived “non-engagement” is often viewed negatively as a bad choice, rather than explored in the context of safeguarding or self-neglect and without exploring capacity.
Even in cases where it appears the risk to the person may be serious, there may be no clear legal grounds to intervene.
What legal frameworks can be applied?
- The Care Act applies to people with alcohol dependency and in particular the inclusion of self-neglect as a form of neglect will encompass many in this group.
- The Mental Capacity Act can be used with people impaired by the effects of alcohol. There are challenges of applying this Act to chronic dependent drinkers because of a lack of specific guidance. However, the concept of executive capacity can be useful.
- The Mental Health Act should be used as a last resort. It specifically excludes people who are solely dependent on alcohol. But there are circumstances in which the Act may be used with people who have other mental or behavioural disorders arising from alcohol dependency.
When should you consider a carer's assessment?
If a person 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.
Further reading and resources
Self-neglect and mental capacity Sussex multi-agency procedures
The Blue Light approach | Alcohol Change UK
Safeguarding adults thresholds | Sussex Safeguarding Adults Policy and Procedures guidance on raising concerns about abuse and neglect
Legal remedies on self-neglect | Sussex safeguarding adults policy and procedures
East Sussex alcohol harm reduction strategy 2021-2026 | East Sussex County Council
East Sussex Learning Portal (ESLP) | East Sussex County Council has courses on self-neglect, trauma-informed practice and the Mental Capacity Act.
