SAR Jack - learning briefing
Background
Jack’s life was defined by:
- the trauma of bereavement
- vulnerability to abuse
- behaviour that challenged professionals
- housing insecurity and street homelessness
- repeated short-term contact with statutory and voluntary services from before he was born until his death.
His adult life was defined by an escalation of the issues which began in his childhood:
- His housing situation remained insecure.
- His use of drugs and alcohol escalated.
- His mental health and wellbeing deteriorated into self-neglect
In the final six months of Jack’s life, his mental and physical health steadily deteriorated. Incidents, often when he was drunk, led to numerous hospital stays, run-ins with the police and short jail sentences.
Prior to his death, Jack made at least 5 further attempts at suicide.
Good practice
- The probation service worked effectively with Fulfilling Lives navigators and Change Grow Live to locate and contact Jack. This helped to secure accommodation for him when he was rough sleeping.
- The Short Sentences Team in the Probation Service built a positive relationship with Jack. He had started to build trust in his case manager, reaching out of his own accord when he needed help. He also attended appointments and shared things about his life and what he wanted for the future.
- Change, Grow, Live identified that Jack would benefit from therapeutic support to explore his childhood experiences.
- A safeguarding planning meeting took place, after two incidents in late 2020 when Jack was stabbed, and went into hospital with a punctured lung. This meeting was well attended by the agencies working with Jack. It considered his housing and the recent death of his grandmother, which is good holistic practice.
- Trauma-informed approaches are being developed and across East Sussex. They try to make physical environments more welcoming, to ‘meet people where they are’. With sensitive curiosity the focus is on what happened rather than what’s wrong.
Key lines of enquiry
The safeguarding adult review identified several lines of enquiry:
- Trauma-informed practice: How is trauma-informed practice embedded and where could this be strengthened?
- Transitions: how is care and support for people living with multiple disadvantage organised to support or reduce frequent moves between services and the associated safeguarding risks of disengagement?
- Professional curiosity and perception: how does stigma and unconscious bias influence the care and support offered and provided to people living complex lives?
- Family and peer involvement: how are families and peers brought in to planning, risk assessment and safeguarding practice supporting adults living with multiple disadvantage?
Key learning
Lead professional arrangements
Building long-term trusted relationships with a ‘lead professional’ is best practice in supporting people who have experienced complex trauma, and self-neglect.
Lead professionals need to use professional curiosity and aim to understand someone rather than to ‘fix’ them. To do this they need permission and support to work flexibly and creatively, to advocate and to take positive risks.
Involving family
For people facing multiple disadvantages, especially those who lost or were estranged from their primary caregivers in childhood, the idea of family may go beyond biological ties. It might not include biological relatives at all.
Try to expand the 'team around the person' approach. Include family, friends and others who can provide non-professional support. This helps strengthen connections, self-worth, and overall wellbeing.
Understanding trauma and behaviour
Research shows that trauma leads to delayed and impaired brain development. This makes it more difficult to establish relationships and to stay on top of responsibilities. For example, attending appointments and following rules.
How might trauma relate to the:
- risks and vulnerabilities they face
- decisions they make
- way they understand and relate to professionals?
Take the time to understand someone and think about what they are good at, not just what they find difficult.
Make time to acknowledge something positive every time you see someone.
Suicide prevention and multiple disadvantage
People who have experienced trauma, drug dependency, previous suicide attempts, or homelessness are at higher risk of dying by suicide.
Although predicting suicide is very difficult, professionals can use risk assessments to identify life experiences and events that increase risk. They also recognise protective factors, support networks, and coping strategies.
Assessments are most effective when you take time to build trust.
- Communicate openly and honestly and work in a transparent manner.
- Be consistent and dependable. Reliability builds trust over time.
- Show empathy and understanding. Listen actively and acknowledge feelings and concerns.
- Demonstrate competence, delivering quality work and making informed decisions.
Breaking cycles of violence
People who sleep rough or face multiple disadvantage often get trapped in cycles of harm and violence.
Trauma and vulnerability are sometimes misunderstood. Men, who are more often seen as perpetrators of violence, can be overlooked when they are actually victims.
For Jack, receiving support to help him understand his relationship with violence both towards himself and others, could have been very helpful.
This support would have been most effective if it was available to Jack even if he was not sober or ‘clean’. Engaging with this type of help might have motivated him to work towards his goal of stopping drinking.
- Find ways to support men by addressing their specific vulnerabilities, without excusing or justifying any violence they may have committed.
Healthy relationships and sexual abuse
It's important to be aware that sexual abuse and exploitation can happen to any adult. This risk is higher for people who have experienced abuse in the past and are vulnerable due to homelessness, addiction, or mental health issues.
- Those working with adults who need care and support should develop their skills to discuss healthy relationships. Speak with your line manager to access training and resources on how to support survivors of sexual violence, including male victims.
Support for survivors of sexual abuse
Survivors Network have services for all survivors of sexual violence, regardless of gender.
Mankind is a Brighton-based charity which supports male-identifying survivors of sexual violence across Sussex. Mankind offer a range of services:
- Self-help resources
- Therapy groups
- Online and in-person therapy
- Educational courses
Further reading and resources
- Mental capacity multi-agency policy and procedures
- Sussex safeguarding adults policy and procedures
- Sussex information sharing guide and protocol
- Safeguarding adults thresholds - guidance on raising concerns about abuse and neglect
- Report a safeguarding concern
- Sussex SAR protocol
- Alcohol related brain damage (ARBD) network
- East Sussex alcohol harm reduction strategy
- Think Family | NHS Safeguarding
- Skills for Care
Multi-agency safeguarding training
For a range of courses, including on self-neglect, trauma-informed practice and the Mental Capacity Act, visit:
