Learning from Safeguarding Adult Reviews in Lambeth
A deep dive into Safeguarding Adult Reviews (SARs), focusing on understanding SAR processes, outcomes of thematic reviews, and considerations for making SAR referrals in Lambeth. Explore the purpose, criteria, and key issues surrounding SARs, along with insights from a thematic review of SAR cases.
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Lambeth Safeguarding Adults Board Learning from Thematic review of SAR H, I and J 22ndNovember 2022 Steve Chamberlain Independent reviewer Lizzy Lacey- Safeguarding adult lead (Lambeth ASC)
Outcomes from todays session To understand what a SAR is and where to find Lambeth guidance To discuss the outcome of SAR H,I and J and findings from this safeguarding adults thematic review. To have break out discussion around learning points from this current SAR and discuss ways we can develop actions from this as practitioners.
Poll What legislation does a SAR come from? What Section of this is used to commission a SAR?
What is a SAR? A Safeguarding Adults Review (SAR) is a multi-agency review which seeks to determine what relevant agencies and individuals involved could have done differently, that could have prevented Serious abuse or neglect or a death from taking place. Under the 2014 Care Act, Safeguarding Adults Boards (SABs) are responsible for Safeguarding Adults Reviews (SARs)- under S.44. This resource aims to help SABs in thinking about how they fulfil those responsibilities. It focuses on a selection of key issues. It is intended to supplement the policy development work already underway or completed by SABs.
Making a SAR referral We currently operate a SAR subgroup as part of the Lambeth safeguarding adults board who as a partnership look at referrals and if a SAR should be commissioned. Any agency, professional or individual can bring a case to the attention of the LSAB and request a SAR if they believe it to fit the criteria listed in SAR guidance (see link at end of presentation) Requests for a SAR must be made in writing using the SAR request form All of the details and policy can be found on the safeguarding adults board website or internally on Lamnet for adult social care and Lambeth council staff (see link in resources)
Things considered in looking at a SAR. a SAR must take place when: an adult dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. adult has experienced serious abuse or neglect, but has not died Some cases referred to the SAR sub-group may overlap with other statutory review processes such as a domestic homicide review, mental health homicide review, MAPPA review, Learning Disability Mortality Review (LeDeR) or a children s serious case review.
Thematic review SAR H, I and J - three individuals Three black British or black Caribbean men All had mental ill health and vascular disease Outcomes Two below-knee amputations One person found deceased at home Decision by SAB to commission thematic review after identifying apparent common elements to the cases Review identified common themes in two cases; one case significantly different
Ivan Jamaican man, 66 years old. Severe cognitive and physical disability following strokes (2008, 2018) Jun 18: discharged from hospital following 2ndstroke Jul 18: referred to podiatry. Seen Sep 18 following 2ndreferral Oct 18: referred to Living Well Network. Seen Jan 19 Feb 19: concern from carers re feet and heels sore with heavy smell, referred to Tissue Viability Nurse refers to Diabetic Foot Clinic (DFC) referrals made to GP for pain management
Ivan 13/03/19: Abortive appointment at Diabetic Foot Clinic after being taken to the wrong part of the hospital 20/03/19: Seen at DFC. Admitted to hospital with necrotic right heel Assessed as lacking capacity for admission, referred for Deprivation of Liberty Safeguards (DoLS) Considered to lack capacity for treatment. Best interests decision for below knee amputation of right leg
Henry Black British man, 58 years old. Long-term diagnosis of paranoid schizophrenia since 1980s, forensic history. Lived in current supported accommodation since 2013 2003: Type 2 diabetes, poor ongoing compliance with diabetic care 2015: Assessed as lacking capacity to manage diabetic care Refused all GP health checks, ongoing concern re. physical health.
Henry Feb 2019: MHA assessment arranged following acute deterioration in mental health Necrotic foot identified immediately before MHA assessment. Taken to KCH A&E, admitted with diabetic peripheral neuropathy and necrotic foot. Below knee amputation in hospital
Jackson 41-year-old black British man, long-term diagnosis of paranoid schizophrenia Prescribed Clozapine over several years. Feb 20: Admitted to hospital on MHA section 3. Diagnosed with type 2 diabetes in hospital, prescribed oral medication Developed severe Diabetic Ketoacidosis in psychiatric care, admitted to KCH, two days in ICU Discharged home on insulin treatment regime for diabetes
Jackson Twice daily visits by LIFT team to monitor Clozapine compliance Daily visits by district nurses (DNs) to administer insulin Personal Assistant (PA) had been visiting before admission, but no longer visiting due to other professionals visiting. Phone contact only Concerns over understanding of diabetes and insulin regime, failed to be home for DNs on several occasions Settled down over summer, but repeated reluctance to take insulin and stay home for DN visits
Jackson Clozapine compliance working well: LIFT reduced visits following reviews, did not inform DN service End of Oct 20: no longer being seen daily by LIFT, numerous failed visits by DNs 02/11/20: failed to attend monthly Clozapine monitory clinic 10/11/20: multi-disciplinary meeting identified Jackson had not been seen by any professional for 10 days. Found deceased at home. Mar 21: Cause of death confirmed as pulmonary embolism caused by deep vein thrombosis. Death by natural causes.
Thematic issues Ivan separate to Henry and Jackson No clear diagnosis of diabetes No evidence of poor or non-compliance with diabetic care No long term mental illness Care planning Professionals awareness of risks relating to diabetic care Multi-disciplinary communication Mental capacity issues (for all three individuals)
Care planning Henry and Jackson both subject to section 117 aftercare (MHA) Duty to provide aftercare to certain categories of MH patients No s117 care plan in existence for either Care plan should include (in addition to mental health care) any specific needs arising from physical disability, etc. Need for care planning for everyone, but explicit statutory by MHA s117 statutory duty placed Care planning is not an end in itself need to address identified problems No coordinating, strategic document pulling together all the care provided by the various agencies or professionals
Risks relating to diabetic care Particular relationship between diabetes and people with chronic mental illness, and those taking long term anti-psychotic medication Evidence of awareness of health problems, but failure to explicitly consider diabetic care, and risks of chronic conditions developing Consideration of use of the MHA in response to increasing health risks, in addition to acute behavioural risks? Trust advice for policy to assess capacity for all individuals with mental illness and diabetes In conflict with MCA case law and new guidance on assessing capacity
Multi-disciplinary communication Much good communication identified Importance of confidence to challenge multi- disciplinary colleagues, and escalating concerns Communication is not an end in itself . Needs to be used to identify difficulties and dilemmas and work to resolve them. Link to care planning with understanding on how to alert colleagues if and when circumstances change
Mental capacity issues Awareness of mental capacity evidenced throughout the cases Inconsistent use of the MCA Use of the 2ndkey principle assisting the person to make the decision Identification of lack of capacity but no best interests decision Inter-professional challenge in contentious issues ability to escalate Capacity assessment for one decision used for a separate decision Need for reassessment and review in cases of possible fluctuating capacity Avoid blanket policies of assessing capacity based on diagnosis or dual-diagnosis (all people with severe mental illness and diabetes)
Recommendations 1. Mental health and Diabetes care Due to the prevalence of diabetes within the population of those people with chronic and severe mental ill health, the trust establishes a professional who can champion diabetic care and provide advice and assistance to colleagues, including escalation to a specialist if necessary. 2. Escalation pathway for MDT supporting chronic patients Community professionals and providers of services to this group of individuals are reminded of the range of chronic and acute outcomes of poor compliance with diabetic care, and advised on how to escalate concerns.
Recommendations 3. Understanding complex decisions and fluctuating capacity. The Safeguarding Board considers how best to enhance understanding of the practical complexities of the MCA across all professionals, Including particular reference to professional differences of opinion, fluctuating capacity and legally robust but proportionate recording of capacity. 4. Ensuring S.117 care plans are completed All individuals subject to section 117 aftercare have a s117 care plan which specifies the range of care and support provided to them, and differentiates the support provided under s117 and that provided under other provisions (e.g. Care Act 2014)
Recommendations 5. Ensuring collaboration and communication on shared Care plans, when they involve multi-agency involvement, include explicit provision for communication between agencies when circumstances change. 6. Annual health checks Where individuals with chronic and severe mental illness refuse or do not cooperate with annual health checks, further consideration is given within the care planning process on how to ensure such health care support.
Resources Easy digestible summary on SARs https://www.scie.org.uk/safeguarding/adults/reviews/care-act LSAB SAR Policy http://www.lambethsab.org.uk/sites/default/files/2020- 06/LSAB%20Safeguarding%20Adults%20Reviews%20Policy%20and% 20Procedure%20March%202020%20update%20v4.pdf Analysis of Safeguarding adults reviews https://www.local.gov.uk/sites/default/files/documents/National%20 SAR%20Analysis%20Final%20Report%20WEB.pdf
