Learning from Ms C Safeguarding Adults Review
Introducing Ms C
Ms C died in hospital during August 2020 at the age of 52. The cause of her death was recorded as decompensated liver, alcoholic liver disease and sepsis secondary to self-neglect and widespread pressure ulcers.
Ms C lived in a one-bedroom upper story flat and with a significant number of physical and mental health challenges. Records describe these as borderline personality disorder (BPD), bipolar disorder, post-traumatic stress disorder (PTSD), hypervigilant hypomania (cyclothymia), morbid obesity, extensive pressure area damage, alcohol-dependence, deranged liver function and liver disease, chronic obstructive pulmonary disorder, reduced mobility, glaucoma, irritable bowel syndrome (IBS), asthma, apnoea, back pain and spinal injury, and cardiomyopathy.
Ms C's physical and mental ill-health impacted on her ability to manage activities of daily living including meal preparation, dressing, personal hygiene and mobilising. One friend living in the same block of flats supported Ms C by preparing meals and dressing her legs. Another friend supported her with personal hygiene. Ms C was estranged from her family due to the pressures associated with her alcohol dependency.
Ms C was reluctant to access support from practitioners. Sometimes Ms C refused physical examinations and participation within assessments and this could involve for example, withdrawing from care arrangements established upon discharge from hospital admissions.
Concerns about self-neglect and about allegations of domestic abuse and retractions of those same allegations were to become a feature of Ms C's interactions with practitioners.
Review methodology
The Safeguarding Adults Review was undertaken in two stages:
- An initial documentary analysis of the submissions from the services involved with Ms C undertaken prior to the coronial inquest.
- A second stage analysis undertaken following the coronial inquest, informed by learning from the inquest and a practitioner learning event.
Review domains
The learning from the review is organised around three domains, each is drawn from the research as to best practice when working to support people who self-neglect:
- Direct Practice: Working with Ms C
A core component of the direct practice domain is engagement. The review noted the challenges around engaging with Ms C who could be reluctant to accept to support. Her friends / carers described Ms C "stubborn" and wanting to be left alone by services.
Healthcare practitioners at the inquest described how Ms C would sometimes cooperate but at other times was resistant to attempts to explore her situation, for example when they responded to her evident distress. They reported difficulty engaging her on some subjects, for example whether or not she would accept different therapies.
Both district nurses and social workers were very concerned in the days leading up to her final hospital admission about her physical health and living conditions. Blood tests had indicated concerns about her liver functioning. Her skin was breaking down, her clothes were damp, malodorous and soiled, and she was descending into a "dreadful state." Meeting her needs was made more complex by having to hold "letter box conversations" when Ms C was either unwilling or unable to open her front door.
In the context of engagement, the review highlights the importance of supportive challenge, concerned curiosity, and consideration of the complexities of mental capacity assessments in the context of self-neglect and alcohol dependency.
- The Interagency Domain: The team around Ms C
The review concluded that whilst there was communication and collaboration between the agencies involved, this did not mitigate the risks. A core component of the evidence-base is the use of formalised multi-agency meetings to ensure that agencies and practitioners work together and implement a risk management plan. Such an approach may have supported practitioners to manage the challenges and complexities of involved in supporting Ms C.
- The Organisational Domain: Organisational support for the team around the person
A core component in this domain of the evidence-base is supervision and management oversight. On the basis of information available, the review concluded that supervision could have been used more to reflect on the approaches being followed. It also notes the workload pressures of practitioners and the adjustments being made to working arrangements caused by the Covid-19 pandemic at the time of these concerns for Ms C.
Learning themes:
The review identified the following themes for potential improvements in practice:
1. Strengthening practice in relation to mental capacity assessment.
2. Strengthening practice in relation to the use and outcomes of the Exceptional Risk Forum to improve case coordination and establish that risk is being mitigated.
3. Strengthening practice by promoting practitioners' skills in:
a) The use of professional curiosity;
b) Managing reluctance to engage;
c) Recognising and working with coercive and controlling relationships within family dynamics;
d) Maintaining awareness of risk thresholds and the necessity to act to manage risk in situations of chronic self-neglect to which practitioners have become accustomed.
4. Strengthening support for practitioners and operational managers across the partnership.
5. Strengthening recording systems and the standard of recording practice.
6. Strengthening supervision policy and practice in relation to complex cases to ensure that circumstances of self-neglect are regularly reviewed by managers/supervisors and are escalated to the Exceptional Risk Forum where necessary.
7. Strengthening commissioning practice for urgent cases.
8. Maintaining a continual focus on self-neglect.
Conclusions
The review concludes:
"What has become even clearer during this stage of the review is the complexity of the physical and mental health issues, substance misuse and relational dynamics involved. The coroner commended the efforts of those involved. Whilst there were, arguably, missed opportunities to obtain a broader picture through more proactive work, formal mental capacity assessments that included executive functioning, and ongoing multi-agency and/or multi-disciplinary meetings, one can only speculate as to their likely impact given the complexity of the case dynamics.
Over two years have passed since Ms C's death and LSAB partners have been implementing an action plan, the elements of which have been developed from this case and the other completed reviews referenced in this report. At the learning event, examples were given of cases where, notwithstanding "daily system pressures", good outcomes have been achieved in very complex self-neglect cases. This has involved the local authority leading on strategy meetings and practice inspired by the evidence-base. This has included persistence when attempting to engage and build relationships with the people involved, and the use of professional challenge in a multi-disciplinary team context."
LSAB response to the review
The Leeds Self-neglect Strategy was developed in response to the learning from Ms C's experiences of support, as well as other learning from Safeguarding Adult Reviews in Leeds. The Leeds Self-neglect three-year Strategy takes forward the learning themes identified within this review as well as the Board's wider ambitions in relation to the support of people who self-neglect in Leeds. This includes the development of multi-agency meeting practices to ensure that agencies and practitioners work together to implement a risk management plan.The approach will be reinforced by individual agency assurance processes.
Further information
It should be noted that this is summary of the review and its findings. If you would like to receive a full copy of the reports, please contact us at LSAB@leeds.gov.uk