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Safeguarding Adult Review Overview Report

Adult G

Author: Hayley Frame

Date: September 2019

Publication Date: 8th October 2019

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1. Introduction

1.1. At the time of the incident that prompted this Safeguarding Adult Review, Adult G, a

51 year old man, was living alone in rented accommodation, was unemployed and in

receipt of benefits. He died as a result of hanging.

1.2. Adult G was born in Yorkshire and was reported to have had a happy upbringing with

his mother, stepfather and siblings. He attended school but left secondary school at

the age of 16 and worked as labourer at a quarry.

1.3. Adult G has two children with his ex-wife. They have remained friends and Adult G

played a significant role in the upbringing of both their children, he gave up work after

the separation and did not work again.

1.4. Adult G became known to Lancashire Care NHS Foundation Trust mental health

services in May 2016 and during the time period between May 2016 and June 2017

the Service User was seen by several services, including six Lancashire Care NHS

Foundation Trust Services; one of which was an inpatient stay as an informal patient.

This admission was following an attempt to take his life by hanging in January 2017.

1.5. The Service User had memory problems which appeared to result in him accruing

overwhelming debt, this was identified as a trigger for the hanging attempt in January,

so much was his debt he could hardly afford to eat, but because of his memory

problems he did not know where his money was going or why he had the debt. His

memory problems meant that before and after his hospital admission, the Service

User often did not attend appointments leading to him being discharged from services,

or not receiving medical treatment.

1.6. Criteria for a Safeguarding Adult Review

A Local Safeguarding Adults Board (SAB) must undertake reviews of serious cases in

specified circumstances. Section 44 of the Care Act 2014 sets out the criteria for a

Safeguarding Adults Review (SAR):

An SAB must arrange for there to be a review of a case involving an adult in its area

with needs for care and support (whether or not the local authority has been meeting

any of those needs) if—

(a) there is reasonable cause for concern about how the SAB, members of it or other persons

with relevant functions worked together to safeguard the adult, and

(b) condition 1 or 2 is met.

Condition 1 is met if—

(a) the adult has died, and

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(b) the SAB knows or suspects that the death resulted from abuse or neglect (whether or not

it knew about or suspected the abuse or neglect before the adult died).

Condition 2 is met if—

(a) the adult is still alive, and

(b) the SAB knows or suspects that the adult has experienced serious abuse or neglect.

An SAB may arrange for there to be a review of any other case involving an adult in its area

with needs for care and support (whether or not the local authority has been meeting any of

those needs).

Each member of the SAB must co-operate in and contribute to the carrying out of a review

under this section with a view to—

(a) identifying the lessons to be learnt from the adult’s case, and

(b) applying those lessons to future cases.

2. Decision to hold a Safeguarding Adults Review (SAR) 2.1. Following referral to the Lancashire Safeguarding Adults Board on 6th November 2017

a decision was made that the criteria for a SAR were met under condition 1 as set out

above. Adult G had died as a result of suicide and there were concerns regarding

agency involvement prior to his death.

3. Methodology

3.1. The methodology for this SAR has been developed to ensure the learning is gained

in an effective and timely way, in line with the Care Act 2014 requirements. The

general principles of the Welsh Model were followed in that the review should focus

upon key learning identified through the review process, allow practitioners directly

working with the adult to actively contribute in identifying learning, good practice and

recommendations, and to ensure a flexible and proportionate response.

3.2. Key aspects of the process included:

Consideration of multi-agency information submitted

The formation of a SAR panel to consider agency information and agree the Overview

report

Discussions with key front line staff via a multiagency learning event being held

Engagement with family members

3.3. Hayley Frame, Independent Reviewer, has been appointed to undertake the SAR.

Hayley is a qualified and Health and Care Professions Council registered Social

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Worker (MA Social Work, DipSW) with 24 years of experience of working within or on

behalf of local government, mostly within the field of safeguarding. Hayley is currently

self-employed as an Independent Safeguarding Consultant and is commissioned as

an Independent Author and Chair for Serious Case Reviews, Safeguarding Adult

Reviews and Domestic Homicide Reviews. She is independent of all agencies

involved in this case and is not from the Lancashire area.

4. Time period over which events should be reviewed

4.1. It was agreed that the scoping period for the review would be from 27th June 2016

until 27th June 2017 (date of death).

5. Agreed terms of Reference for SAR

5.1. determine whether decisions and actions in the case comply with the safeguarding

policy and procedures of named services/agencies and the LSAB

5.2. examine interagency working and service provision for the adult

5.3. determine the extent to which care was person centred and compliance with mental

health act

5.4. examine the effectiveness of information sharing and working relationships between

agencies and within agencies

5.5. explore whether vulnerability factors within the family were appropriately considered

and were responses effective

5.6. examine the awareness and understanding how agencies and practitioners can

challenge peer performance

5.7. understanding the criteria for carers, and the support available for carers under the

age of 18.

5.8. compliance with valid consent and Mental Capacity Act

5.9. establish any learning from the case about the way in which local professionals and

agencies work together to safeguard adults

5.10. identify any actions required by the LSAB to promote learning to support and

improve systems and practice

6. Organisations involved in the SAR

6.1. Organisations involved in the SAR were as follows:

Independent Reviewer

Independent Chair

Adult Social Care

East Lancashire CCG

East Lancashire Hospitals NHS Trust

Lancashire Care Foundation Trust

Lancashire Constabulary

7. Involvement of Family Members and Significant Others

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7.1. The LSAB wrote to the family and attempts to visit the home were made by the SAR

Panel Chair and the LSAB Business Coordinator. Unfortunately these attempts were

unsuccessful. A decision was made to write to the family again; with questions for

them to consider and respond to, if they so wished. The son of Adult G wrote back

and his perspectives are included within this report.

7.2. On behalf of the Lancashire Safeguarding Adults Board, the Independent Reviewer

expresses her gratitude to the family for their contribution, at a time when they are

grieving and feeling failed by the services that should have supported Adult G.

8. Parallel Investigations

8.1. A Post Incident Review (PIR) was completed by Lancashire Care NHS Foundation

Trust.

8.2. An inquest concluded in December 2017, finding that Adult G died by suicide.

9. Significant events within scoping period (summary of multiagency chronology)

Author comments are in bold

9.1. In May 2016, Adult G was referred to the Mental Health Assessment and Treatment

Team following his intention to hang himself 3 weeks earlier.

9.2. In June 2016, Adult G went to see his GP as he was concerned about his memory

loss which he reported to be getting worse. He was referred for blood tests and to the

Memory Assessment Service. The referral stated that Adult G was getting very

forgetful; symptoms had started approximately 2 years ago. He was forgetting

people’s names and unable to concentrate. On examination his cognitive impairment

score was 20/28.

This score highlights significant cognitive impairment so a referral to the

Memory Assessment Service was good practice.

9.3. The blood tests results indicated vitamin B12 and iron deficiencies. Adult G was then

started on a course of vitamin B12 injections.

9.4. On 27th June 2016, a Psychological Wellbeing Practitioner spoke with Adult G

following receipt of the referral to the Mental Health Assessment and Treatment Team.

Adult G shared that he felt generally depressed. He said that he had raised his son

as a single parent since he was 2 and is now 17 years of age. Having not worked for

20 years he had recently began to try and find employment and had become very

disillusioned with the experience as there was nothing available. Asked how he

spends his day he replied that he typically stays in watching TV. Adult G denied any

current suicidal thoughts and was willing to accept an appointment with Assessment

and Treatment Team. Adult G also agreed to a referral to Community Restart Team

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to assist with employment and social inclusion. For Adult G this was working on a local

allotment, as part of the Open Gate gardening project. Adult G engaged well with

Open Gate, attending independently twice a week.

The Psychological Wellbeing Practitioner who spoke with Adult G showed good

understanding of needs and risks and referred quickly to other services within

the Trust.

9.5. Adult G did not attend his appointment with the Mental Health Assessment and

Treatment Team on 7th July 2016. The practitioner attempted to telephone Adult G but

the call went straight to voicemail. A request was made that the case be discussed in

the Multidisciplinary Team (MDT) meeting the following day.

There is no evidence of liaison with other mental health services within the

Trust to establish a means of contacting Adult G. It was however good practice

to discuss within MDT regarding another appointment prior to discharge.

9.6. On 8th July the MDT meeting was held. It was decided that the risk was low and not

immediate and a second appointment was offered for 20th September 2016.

It is not evident what additional information was considered that resulted in low

risk being identified.

9.7. On 18th July 2016, the Memory Assessment Service attempted to contact Adult G by

telephone to complete the MRI imaging details. They could not make contact.

It is good practice for the service to telephone a service user, however it is

unclear if they had correct contact details as other services within the Trust

reported they were wrong on the system.

On-going work is taking place with commissioners and GP Practices to ensure

where possible and, following gaining consent with the patient, that details of

next of kin or significant other are attached to the referral form. They can then

be contacted if attempts to contact the service user fail.

9.8. 16th August 2016, Adult G attended for an MRI scan and the MRI scan results were

reviewed by consultant psychiatrist on the 23rd August 2016 but a follow up

appointment was not sent until 6 months later.

The review has identified that there were unacceptably long waiting times for

service users who were waiting for results for MRI scans. MRI results are

viewed, checked for any urgent medical factors which need further intervention

and if no acute issues are identified then the service user will receive an

appointment in waiting list order. The follow up waiting list in August 2016 was

6 months.

9.9. On 5th September 2016, Adult G attended the Memory Assessment Service. He spoke

of a history of suicidal thoughts and attempts to hang himself. With regard to his

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memory, Adult G stated that he forgets people’s names, misplaces personal items,

gets lost in familiar places and has poor concentration. He also spoke of problems

paying bills and now being in arrears. Adult G informed the nurse undertaking the

assessment that he had had an MRI scan, but the results were not available to the

nurse.

The Nursing Assessment was holistic and included a risk assessment and

memory assessment. However, the Nurse undertaking the assessment was

unaware that a MRI scan had taken place and the results had been reviewed by

the consultant. There was no evidence as to where the results could be found

within Adult G’s notes. The letter that contained the results of the MRI scan was

not added to Adult G’s notes until 5th December 2016. The reason for this is

unknown and the delay would not be in accordance with expected practice. An

admin review has been undertaken as a result.

9.10. Adult G attended his appointment with the Mental Health Assessment and

Treatment Team on 20th September 2016. Adult G shared that he had memory

problems and had attended for an MRI scan but was unaware of the results. No

current risk of plans or intent to self-harm was identified. Adult G denied any history

of alcohol or substance misuse. It was recorded that his capacity was ‘intact’ with

regards to treatment although not formally assessed. A further appointment for the

14th November 2016 with a psychiatrist was arranged to discuss medication options

given his low mood.

The nurse assessed and found Adult G’s presentation warranted a further

assessment with a medic appointment being offered in November. This was

nearly two months after his initial appointment and there are no current

performance measures in place for the timing of review appointments. Although

no safeguarding issues were identified at this appointment, consideration was

not given to the impact of his undiagnosed memory problems. The nurse should

have checked the electronic records, for any current involvement with other

services within the Trust.

9.11. Adult G did not attend the appointment on the 14th November 2016 and

following a discussion at the multidisciplinary meeting he was discharged as he was

felt to be low risk. The GP was informed.

It is good practice to have the MDT discussion following missed appointments.

It has not been possible to establish what additional information was sought

that indicated that Adult G was at low risk and therefore discharge appropriate.

The DNA was not followed up by the GP practice which would have been

appropriate given their knowledge of Adult G’s memory problems.

9.12. On 5th December 2016, the letter containing the review of the MRI results was

added to Adult G’s notes. The results did not indicate abnormalities that would lead to

memory loss.

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This letter was signed as having been seen by Consultant Psychiatrist on the

23rd August 2016. It has not been possible to clarify where this information was

stored until it was scanned onto Adult G’s notes. The information within this

letter would have been beneficial to the memory assessment practitioner who

undertook assessment 5th September 2016. As stated earlier, in August 2016

there would have been a long wait for an appointment to see the consultant for

delivering a diagnosis however the information should have been available

within the Trust way before then.

The Memory Assessment Service (MAS) Standard Operating Procedure has

been revised as a result in order to improve administrative processes. There is

now in place a Patient waiting list to map the patient’s journey through MAS.

Medical Secretaries, MAS administration, the MAS Performance Manager and

MAS Team Leader have access to the waiting list. Waiting lists are updated

when MRI investigations are received back into MAS services for outpatient

appointment booking. This is now reported monthly to senior management and

commissioners regarding waiting times for diagnosis.

9.13. On 3rd January 2017, Adult G attended the Emergency Department with his son

having attempted to hang himself the previous evening. Following a mental health

assessment, he was then admitted on an informal basis to hospital. Adult G remained

in hospital for over a month, until he was discharged on 6th February 2017.

9.14. Whilst an inpatient, Adult G’s MRI scan results were reviewed and a request

made for a referral to neurology. A referral to social care was also made given

concerns regarding Adult G’s home circumstances including self-neglect.

Inpatient staff telephoned various trust departments to try to obtain the MRI

results. However had they checked the Adult G’s notes, the results had been

scanned in on the 5th December 2016. This evidences that a full review of his

notes and history did not take place when he was admitted to hospital. The

inpatient staff only spoke to the Memory Assessment Service when Adult G had

already been an inpatient for over two weeks.

Practitioners did not access the MRI results from the electronic document

management system although it was acknowledged that the system could be

difficult to navigate.

There is no evidence of a referral being made to neurology. The reasoning for

this is not unknown and is not in accordance with expected practice. The review

has been informed that there were specific practice issues with regard to a

locum psychiatrist who oversaw Adult G’s care whilst an impatient. Ward staff

had concerns, which were discussed with managers and the locum psychiatrist

but not escalated further. The psychiatrist is no longer employed by the Trust

and processes have been established for reporting concerns which are now

overseen by senior management.

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9.15. During Adult G’s admission, a discussion took place between a clinical

psychologist and a neuropsychologist and it was agreed that further advice would be

sought from an Older Adult Psychiatrist. Following this, it was agreed that the

neurological opinion would be awaited, although this was based on the belief that a

referral to neurology had been made.

9.16. Whilst an inpatient, Adult G cited money problems as a significant stressor and

reported his money went very quickly on bills, and that he was living on chips to save

money. Adult G said that his money was spent on the day he received it but he had

no idea where it went. Adult G’s son reported to ward staff that he had been to his

father’s house and found paperwork relating to debts with finance companies and

council tax. Ward staff helped Adult G in terms of liaising with his debtors and

arranging repayments however again no consideration was given to the root causes

of his debt.

No safeguarding or mental capacity assessments were discussed and there

was no exploration of the reasons behind his ongoing financial difficulties.

Although lots of support was given to managing the debts and repayments

there were no investigations as to where his money was going or the impact of

reported memory issues on his ability to manage his finances. The focus

appeared to be on debt management as opposed to establishing diagnosis and

an ongoing treatment plan.

9.17. Whilst an inpatient, the Addenbrooke’s Cognitive Assessment III was

completed and recorded a score of 72/100. This score was below what was expected

and based on this score it was agreed there would be further functional (Occupational

Therapy) assessments.

The completion of functional (occupational therapy) assessments means the

team could then make adaptations to the Adult G’s home environment to

support his strengths and compensate for the weaknesses. It was appropriate

given the Cognitive Assessment findings for further assessment in Adult G’s

home to be completed. However this was not actioned because he was

discharged before this could be completed.

9.18. The ward psychiatrist also asked that Adult G be seen by the Memory

Assessment Service prior to his discharge.

This did not occur as MAS were not informed of Adult G’s subsequent

discharge.

9.19. Prior to his discharge, discussions also took place regarding liaison with the

crisis team to provide support in the community. In addition it was recorded that he

had been referred to the community mental health team.

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There is no evidence of this referral having been made which would have been

expected practice.

9.20. On 6th February 2017, a review took place attended by Adult G and his son,

also present was the Inpatient Consultant Psychiatrist, Ward Doctor and Staff Nurse.

Adult G reported feeling well; he denied further suicidal thoughts or plans, and his

son said that he noticed a significant improvement and his dad was 98% back to

normal. Adult G when asked what had changed reported his bills were now paid; he

said he felt ready to go home and would not get to that low point again. The inpatient

Consultant Psychiatrist advised a referral had been made to Adult Social Care but the

outcome was not known, and also said it would be better if Adult G waited for

discharge until he had a Care Coordinator allocated. However, on Adult G’s

insistence he was discharged from the ward.

The discharge process was rushed and not all of the relevant professionals

were at the review. Adult G was discharged without a full MDT discussion which

would be the standard practice when considering discharge after such a

significant attempt at taking his life by hanging. There were clear issues around

his health yet there was still no diagnosis or identification of what could be the

cause of the memory problems in a man of his age. Adult G was discharged

without all of the assessments identified on admission being completed i.e.

Occupational Therapy assessment in the community & home environment. No

care co-ordinator was identified and neither Adult Social Care nor the Memory

Assessment Service were informed of the discharge. Throughout his inpatient

stay, ward staff worked with Adult G in resolving his debt and housing

conditions. However housing authorities were not involved in any of the

discharge process and there are no clear plans to support how risks would be

managed in the community or who would support Adult G. There were no

agreed multi agency risk management strategies identified. The discharge

refers to community mental health team and neurology referrals yet there is no

evidence to support these referrals having being made which would have been

the responsibility of the overseeing inpatient psychiatrist.

In response to a number of issues regarding inpatient consultant cover, there

is now a new model developed called ‘sectorisation’. This model is based on

locality and utilises the community consultant attached to specific GP practices

to cover a specific inpatient mental health ward. Each Consultant is based on

the ward one day per week. It is anticipated that this will improve continuity as

the patient will be managed by the same Consultant when an in-patient and

whilst in the Community.

9.21. On 8th February 2017, two days after discharge from the ward, Adult G was

seen in the community by the crisis resolution home treatment team. He presented

well and reported no mental health difficulties and as a result was discharged.

It is in accordance with Standard Operating Procedure that the visit by the crisis

team should occur within 48 hours of discharge. It is unsurprising that Adult G

was still feeling well at this stage so soon after discharge. It was recorded prior

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to discharge from his inpatient stay that a referral to the community mental

health team had been made but this did not occur which is a clear practice

omission.

9.22. That same day, email correspondence was exchanged between the Older

Adult Consultant Psychiatrist, the Clinical Psychologist and the Memory Assessment

Service Consultant Psychiatrist. It was recommended that assertive follow up was

required in the community, a prompt medical opinion regarding the cause of his low

vitamin D, a range of tests for inflammatory markers for unusual causes of dementia

plus pursuing a neurological opinion.

As stated above, the referral to neurology never occurred which is a clear

practice omission.

9.23. On 20th March 2017, Adult G’s son contacted the crisis team for advice as his

mother had found his father with a knife and having attempted to hang himself. He

was advised to contact the police. The police and ambulance service were contacted

and Adult G was taken by ambulance to hospital. Adult G was assessed by the

psychiatric liaison team having been reported to have tried to hang himself. Adult G

told the assessing nurse this was not the case, stating that he had thought about it

the previous week but the attempt had been disturbed. He reported low mood

triggered by money worries and stated that he had not achieved anything from his

recent hospital admission. He denied alcohol use but reported on occasions he

smoked cannabis. Adult G denied further suicidal thoughts and agreed he might

benefit from antidepressant medication. He was advised to see his GP about this and

was discharged with the contact number for local crisis team.

It is of concern that the same triggers for his low mood and suicidal thoughts

were identified yet there is no understanding of how he is to be supported with

his financial difficulties or the impact of his memory problems upon them. This

was also Adult G’s third attempt at making a noose.

9.24. On 21st March 2017, Adult G did not attend the Memory Assessment Service

and was therefore discharged.

Had Adult G’s notes been checked, it would have been clear that he was in crisis

and in hospital the day before which may have prevented his discharge from

the MAS.

9.25. On 22nd March 2017, a Social Worker from Adult Social Care attempted to visit

Adult G at home. This was following the referral made whilst he was still an inpatient.

Despite knocking, there was no response. The Social Worker was tenacious and

made various telephone calls to professionals and was then aware of recent events.

She was concerned for Adult G’s safety and contacted the police. The police were

able to speak with Adult G’s ex-wife who confirmed that he was safe and well.

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9.26. On 27th March 2017, the Social Worker visited Adult G at home, in the company

of his ex-wife. Adult G did not wish to consider support from Adult Services. He agreed

to a referral to the Lancashire Wellbeing Service who could support with benefits and

money management.

The social worker was aware of all of the history and had been very concerned

for Adult G’s welfare yet was reassured by his positive presentation. Although

he was given details of agencies that could have provided support, no capacity

assessment regarding managing his own finances was undertaken or other

options considered. Adult G had been hospitalised after an attempt to hang

himself stating financial burdens were a contributing factor, and only a matter

of months later the same issues are apparent.

9.27. On 21st April 2017, Adult G was seen by his GP. Adult G was referred back to

the Mental Health Assessment and Treatment Team. He was offered an appointment

on 24th May 2017. This appointment was not attended and a second appointment was

offered on 19th June 2017. Adult G also failed to attend this appointment. He was

therefore discharged.

Adult G was offered an appointment a month after the referral and no plan was

in place to support his attendance given the length of time to the appointment

and his well documented memory issues. Whilst at this point Adult G did not

meet the criteria for referral to the Home Treatment Team, there could have been

some dialogue with them to look at possible options due to continued non-

engagement with offered appointments. His discharge from the Team appeared

to take place without the risks being fully considered, there was failure to

actively engage with Adult G, and consider his past history.

9.28. The police were contacted on 20th June 2017 by Adult G’s ex wife concerned

for his safety. A police officer located Adult G at a park and took him to the Emergency

Department. The police officer did not wait with Adult G. He was seen by a triage

nurse and he informed her that his only problem was that he had run out of prescribed

medication for depression. He denied any low mood. He was advised to see his GP.

It would not be expected that the police officer wait with Adult G as he was

attending the Emergency Department on a voluntary basis. However the impact

of this was that the triage nurse was not aware of the full situation as there was

no opportunity for the police officer to relay the history. This left the triage

assessment to be based on only what Adult G was reporting, and his cognitive

difficulties might have impacted on the accuracy of the account provided.

9.29. The police officer had completed a Vulnerable Adult referral which was good

practice. This referral was screened by Adult Social Care and the Mental Health

Assessment and Treatment Team Duty Worker. The Adult Social Care Social Worker

spoke with Adult G on 23rd June 2017 and then with the Wellbeing Service who

confirmed that they were working with him. Concerns were raised regarding him

having no money or food. It was also confirmed that he had been discharged from the

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memory assessment service and mental health services due to non-engagement. It

was decided that there were no identified social care needs.

The review has established that the social worker was referring to Adult G as

not presenting with 'eligible social care needs' under Section 1 of the Care Act

2014. However a much more robust rationale should have been recorded. It

would have been expected that some reference to the information as provided

by the PVP would be relevant to the decision. There is evidence that suggests

a possible mental impairment, both in the PVP and as referred to in previous

case note entries. There is evidence to suggest that Adult G was not managing,

to a degree that would have significant impact on his wellbeing.

9.30. As a result of the Vulnerable Adult Referral, Adult G was again discussed within

the Multidisciplinary Team Meeting within the Mental Health Assessment and

Treatment Team. It was agreed that an appointment would be offered for 10th July

2017.

9.31. On 27th June 2017, Adult G died as a result of hanging. He was found by his

son.

10. Practitioner Perspectives

10.1. The Memory Assessment Service Nurse who first saw Adult G on 5th

September 2016 recalled that he had a history of self-harm and attempted hanging

although he was not feeling suicidal when they met. He had protective factors,

including his son and was enjoying gardening which was giving him purpose and

direction. Adult G did talk about debt and was struggling with bills that he kept

forgetting. They talked about a strategy and using CBT which Adult G agreed to do.

The nurse felt that after the assessment Adult G was ‘in a good place’ and was

satisfied that there was no risk.

10.2. The Consultant Psychiatrist from the Memory Assessment Service confirmed

that the results of the MRI scan did not indicate a need for any immediate action and

that there was nothing to indicate that Adult G had a neurodegenerative disorder. The

MRI scan results were not linked to his memory loss. His view was that the memory

problems would be best addressed via the continuation of vitamin B injections.

10.3. The Manager of the Community Restart Team stated that Adult G attended the

gardening project twice a week without fail, and that he was a trusted member of the

volunteers. Adult G was trusted with the code to gain access to the allotment which

he would have either had to remember, write down or store on his phone.

10.4. Staff from the ward where Adult G was an inpatient, recalled how at first he

never took off his thick coat and boots, and would sleep in his coat. He was quite

guarded at first. It was shared that there were clear memory problems. Adult G had

brought a big bag of potatoes with him that he was eating at home and stated that

was what he was living on. He shared with ward staff that his finances were ‘in a mess’

and he had several loans. These debts were addressed whilst he was an inpatient.

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10.5. The social worker who visited Adult G at home on 27th March 2017 reported

that she had no reason to doubt his capacity. His home was not in squalor, as

previously reported, although he did report difficulties with debts and therefore finding

it difficult to buy food for himself and his dog. It is clear that the social worker was

reassured by Adult G’s presentation.

10.6. The Acute Trust Triage nurse who saw Adult G on 20th June 2017 was unaware

of the events that led to Adult G being brought to hospital by the police, hindered by

the fact that the police officer left Adult G without speaking to a professional. In

addition, the Triage nurse reported that she would see 56 patients per shift and is

given an 8 minute target to see the patient and then record the notes. This significantly

impacts upon the ability to ascertain any other information other than that which is

self-reported. Adult G denied having low mood or suicidal ideation and stated that he

only wanted repeat medications. She explained to Adult G that the Emergency

Department is unable to do this and he then left the department. The Triage Nurse

reflected that a quick conversation with the police officer would have made a

difference to her triage as she would have asked different questions. The Triage Nurse

stated that she was going to speak with her Matron about developing a basic form for

the Emergency Department receptionist to give a police officer to provide bullet point

information or a telephone number so that they can be contacted to provide the

background information if they need to leave the Emergency Department quickly.

10.7. Discussions took place regarding the management of referrals into the Mental

Health Assessment and Treatment Team and that given the number of referrals made

in respect of Adult G and his repeated failure to attend appointments, whether a

different approach could have been considered such as a request that he be seen by

the Home Treatment Team. Now within the Multidisciplinary Team meetings that

consider referrals, they will access records to see whether there are repeat DNAs and

whether this is an indication of the need for a different response.

10.8. It was shared that during the inquest information came to light to suggest that

Adult G had a ‘pact’ with his youngest son that if he was concerned to knock on the

door three times and if no answer to break the door down. Had professionals had

knowledge of this pact, this would have been considered as part of his discharge from

hospital and would have heightened the perceived risk.

10.9. In addition it was noted that Adult G was known to 6 different departments

within the same trust yet information sharing was poor and there were different

recording systems within different departments. The introduction of a Trust wide

recording system in 2020 will address this risk factor. The need for up to date details

of the next of kin and permission to contact them in the event of appointments not

being attended was also discussed. There are now clinical audits of records occurring

as a result of this review.

11. Family Perspectives

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11.1. Adult G’s son provided a written submission to this review. He described his

father as a caring family man who loved his children and his dogs. In recent years he

had become withdrawn and quiet shutting himself off from friends. His ex-wife and

son would see him daily and it was shared that his memory loss led to him missing

appointments and that he would often leave letters unopened. This meant he was

discharged from services and did not get the support that he needed.

11.2. Adult G’s son felt that he and his mother were left to cope alone with no

community support or follow up and that his father was ‘totally let down by services’.

12. Emerging themes

12.1. It is evident that Adult G’s financial difficulties impacted upon his physical and

emotional wellbeing. Adult G shared with professionals that his benefits would be

spent in one day and that he would not know where the money had gone. It was clear

that he was not coping at home, and whilst an inpatient he shared that he would leave

the gas fire and electric oven on and spoke of a lot of debt collectors knocking at his

door. He would try to use strategies to help with his poor memory such as putting

paperwork in his pockets but would then forget that they were there. Whilst an

inpatient, a Recovery Practitioner contacted Adult G’s debtors and offered carers

support information to Adult G’s son. It is evident however that financial pressures

continued following Adult G’s discharge from hospital. Due to his debts, and inability

to manage his finances, Adult G neglected his diet which would have impacted on his

physical and no doubt mental health.

12.2. Concerns have been identified regarding the management of Adult G’s care

whist an inpatient. His care should have been delivered under the Care Programme

Approach (CPA) framework but no CPA documentation was completed whilst he was

in hospital. Adult G clearly met the requirements for this approach and the inpatient

Standard Operating Procedures were not followed although the reason for this is not

clear.

12.3. The Inpatient Standard Operating Procedure states a Care Programme

Approach meeting should take place within 72 hours of admission, and the Care

Programme Approach Policy states there should be a planned Care Programme

Approach discharge meeting. In addition to the Inpatient Standard Operating

Procedures indicating that all service users should have an initial CPA meeting, the

CPA policy also identifies some areas whereby a service user would be deemed

eligible for CPA such as:

Risk of suicide

Self-neglect

Being a vulnerable adult for example having cognitive difficulties

Having the need for multi-agency input such as housing, physical care, employment

and voluntary agencies.

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It is evident that Adult G met all 4 of these criteria. It is recognised that LCFT have all

appropriate CPA policies in place and that these can now be subjected to real time audit.

12.4. It has been established that Adult G was discharged from hospital in haste and

without key professionals being part of the discharge plan. Had the CPA framework

been followed, Adult G would have had a planned CPA discharge meeting. The

Inpatient Consultant Psychiatrist felt it would be better that Adult G remained in

hospital until a care coordinator was allocated but Adult G insisted that he be

discharged. However a Care coordinator is normally allocated as soon as a patient is

admitted. There is reference to referral being made to neurology and the community

mental health team prior to discharge but these referrals were never made. The

discharge plan did not detail any requests for further assessment, home treatment or

community support. In addition, as his cognitive difficulties were not fully understood,

consideration should have been given to the risk of Adult G’s social and financial

vulnerabilities impacting again upon his mental health when back in the community. It

is evident that the practice issues of the Inpatient locum psychiatrist impacted upon

the quality of Adult G’s care.

12.5. There is no documentation to suggest that Adult G’s cognitive difficulties were

considered in terms of impact on his capacity to consent to treatment, and in this case,

his capacity to refuse longer hospital admission and insist on discharge against

medical advice.

12.6. It was known that Adult G was Vitamin B12 deficient and that this can cause

health problems that include memory loss and psychological problems including

depression and confusion. The Consultant Psychiatrist from the Memory Assessment

Service was of the professional view that this was the most likely cause of Adult G’s

difficulties.

12.7. Adult G often did not attend appointments, and was therefore repeatedly

discharged from services. Greater understanding of his memory difficulties would

have provided an explanation for his failure to attend appointments. Had he had an

allocated Care Coordinator this may have been better understood, more assertively

followed up, and Adult G may have received the services and support that he needed

in the community. In addition, decisions to discharge were often made on the basis of

inaccurate information – such as the Memory Assessment Service discharging Adult

G due to non attendance (which had they checked the notes it would have been clear

that Adult G was at that point in crisis having attended the Emergency Department

the previous day) but also due to the belief that a referral had been made to neurology.

Again a care coordinator would have been the key professional to ensure that

appointments were attended and to establish the progress of referrals made. In

addition, it would be prudent for services such as the Memory Assessment Service to

copy appointment letters to the next of kin given the inherent risk of appointments

being forgotten by those referred to the service.

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12.8. In addition, appointments with the Mental Health Assessment and Treatment

Team were often significantly delayed from the point of referral/decision to offer an

appointment – sometimes up to 10 weeks later. It has been established that high

referral rates and staff sickness meant that waiting lists increased. The Operational

Procedures state that the wait from referral to appointment should be 10 days

although the timescale for appointments offered following DNA are not measured.

12.9. The referral made to Adult Social Care whilst Adult G was an inpatient, was

made on 5th January 2017. However Adult Social Care were not made aware of Adult

G’s discharge. As the referral appeared non urgent, it was not actioned until the

beginning of March 2017. Adult G did not want services from Adult Social Care so the

case was closed. Adult G presented positively to the social worker who presumed that

he had capacity to manage his home circumstances.

12.10. When the police officer completed a Vulnerable Adult Notification following his

contact with Adult G on 20th June 2017, this was again screened by Adult Social Care.

The referral clearly detailed a number of vulnerabilities yet these were not felt to meet

the criteria for Adult Social Care. This decision is questionable, and appears to have

been influenced again by Adult G’s positive presentation despite knowledge of the

history of concern.

12.11. There is reference made to the support provided by Adult G’s ex-wife and son,

who was only 17 years of age. Safeguarding procedures in respect of his son were

not considered at any point. Although carer support was discussed on one occasion

whilst Adult G was an inpatient, no referrals were made for a carers assessment.

There was no clear assessment of what Adult G’s care needs were, therefore no

clarity regarding the tasks and challenges for his carers and what support they might

require. It is not evident whether the family members knew how to make a complaint

if they were dissatisfied with services.

12.12. It appears to be evident that Adult G’s vulnerability factors were never

addressed. The significance of this is that there was a clear and repeated link between

these factors spiralling and Adult G’s attempts of hanging.

13. Recommendations

13.1. Learning from this review will be disseminated to all relevant service areas.

13.2. Mental capacity involves not only the ability to understand the consequences

of a decision, (decisional capacity), but also the ability to execute, or carry out, the

decision, (executive capacity). Agencies are to consider providing case examples

within their training to support professionals in understanding the difference between

decisional capacity and executive capacity. Agencies should also reiterate the

importance of recording capacity assessments and best interest decision making to

demonstrate defensible decision making.

13.3. The Lancashire Care NHS Foundation Trust DNA policies relating to memory

services to be amended to give specific reference to patients with cognitive difficulties.

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This should include consent for contact with the next of kin and a prompt for

reasonable adjustments to be made as part of the person’s care plan to facilitate their

engagement.

13.4. The Lancashire Care NHS Foundation Trust to provide assurance that

information sharing within and across the departments within the Trust is robust, up

until the point and whilst the new Trust wide recording system is being implemented.

This will include ensuring that relevant protocols and policies detail the professional

accountability of staff undertaking assessments to demonstrate they a) have

assertively sought to access and consider any existing Trust information relating to a

new assessment and b) that they have assertively sought to share any information

their assessment has gleaned, including non-attendance with any other Trust services

involved. It is recognised that this already forms part of the LCFT action plan.

13.5. The Lancashire Care NHS Foundation Trust to provide assurance that

professional practice issues are identified and managed effectively. This includes staff

being aware of whistle blowing procedures. It is recognised that this already forms

part of the LCFT action plan.

13.6. The Lancashire Care NHS Foundation Trust to ensure that its staff are aware

of the process for identification and referral for carers assessments, especially in

cases of young carers who may have unmet needs.

13.7. Agency complaints processes should be explained and be made available to

patients and relatives, and provided in a format which is accessible to the patient.