Mrs. Hanson Safeguarding Adult Review: Case Overview & Insights
In this Safeguarding Adult Review, explore the case of Mrs. Hanson, her background, care situation, and critical incidents leading to a need for respite care. Gain insights into the importance of proper safeguarding measures for vulnerable adults and the role of care services in ensuring their well-being.
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Adult C Mrs Hanson Safeguarding Adult Review Bernadette Dean Professional Lead for Safeguarding Pennine Care NHS Foundation Trust Andy Jones Deputy Head of Service, Rochdale Adult Care www.safeguarding4rochdale.com
Briefing Introduction Safeguarding Adult Review process Case overview Learning Three things Q&A www.safeguarding4rochdale.com
Introduction This Safeguarding Adult Review is about Mrs Hanson who until January 2015 was living with her husband in unsupported accommodation owned by a housing association. Mrs Hanson was born brought up and educated in Rochdale. She was one of four siblings. She worked in the local cotton industry and for several years was an usherette in a local cinema. Mrs Hanson was married for over 60 years and had two children, one of whom died in an accident aged twelve. Mr Hanson survived his wife and died in 2016. www.safeguarding4rochdale.com
Introduction Mrs Hanson s son, Tony, describes his mother as intensely independent, morally robust and not one to make a fuss. Mrs Hanson had a strong Christian faith. Tony would like his mother remembering as a generous person who cared about other people and often championed causes for them. She was warm and funny; a thoroughly decent and well respected person. www.safeguarding4rochdale.com
Introduction It has been reported Mrs Hanson had not left the flat for about two years because of mobility problems. Mr and Mrs Hanson were supported by their son Tony. Additionally, Rochdale Council Adult Care Services commissioned a service to provide four daily visits to Mrs Hanson to assist her with personal care, the preparation of meals and to monitor her medication. It now transpires that the care staff never attended to Mrs Hanson s personal care as she was always up and dressed before they got there, a fact it appears was known to Adult Care Services. www.safeguarding4rochdale.com
Introduction Mrs Hanson was being treated for a urinary tract infection and on 17 January 2015 she fell three times in the flat. Tony called North West Ambulance Service because he suspected his mother had a serious water infection. Paramedics attended and felt Mrs Hanson needed respite care and advised Tony to contact the Emergency Duty Team at Rochdale Adult Care Services. The Emergency Duty Team arranged for the out of hours District Nursing Service to complete a Social Care Assessment. This resulted in Mrs Hanson, accompanied by her son, arriving at the care home about 1.00 am on 18 January 2015 for respite care. At that time Mrs Hanson was not known to have any pressure ulcers but the care home staff did note her bottom was bruised which they thought resulted from the falls. www.safeguarding4rochdale.com
Introduction On 26 January 2015 a district nurse examined Mrs Hanson and discovered a grade 4 pressure ulcer. An ambulance was called and Mrs Hanson was admitted to Hospital where she died in the early hours of the following morning. A grade four pressure ulcer is the most severe type of pressure ulcer. The skin is severely damaged and the surrounding tissue begins to die [tissue necrosis]. The underlying muscles or bone may also be damaged. www.safeguarding4rochdale.com
Safeguarding Adult Reviews (SAR) The Care Act 2014 introduced new responsibilities for Safeguarding Adult Boards. These include the requirement, when certain criteria are met, to undertake reviews of cases involving an adult Rochdale Safeguarding Adult Review process Publication and actions www.safeguarding4rochdale.com
Services Involved Rochdale Borough Council Adult Care and Support (RACS) North West Ambulance Service (NWAS) Heywood, Middleton and Rochdale Clinical Commissioning Group (HMR CCG) Care Home www.safeguarding4rochdale.com
Case Overview - Timeline 17thJanuary 2015 Tony visited his mother and discovered she had fallen three times that day. He called an ambulance as he thought she had a serious water infection. Paramedics assessed Mrs Hanson in Tony s presence and felt that a respite bed was the most suitable option. A paramedic spoke to the GP out of hours service resulting in the paramedic advising Tony to contact Rochdale Adult Social Care Emergency Duty Team to arrange a respite bed. Tony spoke with a social worker in the Emergency Duty Team who arranged for a district nurse to complete a Social Care Assessment for Mrs Hanson. www.safeguarding4rochdale.com
Case Overview - Timeline That assessment led to an Emergency Duty Team social worker authorising an initial two weeks respite care in the care home. The district nurse made a referral to the Access and Enablement Team at Rochdale Adult Social Care for review on the next working day, Monday 19 January 2015. www.safeguarding4rochdale.com
Case Overview - Timeline 18thJanuary 2015 Mrs Hanson arrived at the care home by ambulance. Entry from Care Home Service Users Information Sheet. Admitted 0100 hours. X3 fall at home; bottom bruised and swollen. District nurse delivered Social Care Assessment [also referred to as FACE Background Information] to the care home. Body map completed by registered manager of the care home. Very dark bruising and swelling to buttocks noted [Query?] pressure area. No obvious wounds but extensive bruising to buttocks, legs and chin . www.safeguarding4rochdale.com
Case Overview - Timeline Care plan documented by registered manager: The care plan had the following sections. Manual handling Falls risk assessment [high] Personal care Pressure ulcer prevention/identification Communication assessment Mobility plan Continence care Medical history-medication www.safeguarding4rochdale.com
Case Overview - Timeline Waterlow assessment showed Mrs Hanson was at very high risk of pressure ulcers. The score was 20. The Waterlow pressure ulcer risk assessment/prevention policy tool is, by far, the most frequently used system in the U.K. and it is also the most easily understood and used by nurses dealing directly with patient/clients. www.safeguarding4rochdale.com
Case Overview - Timeline 19thJanuary 2015 Mrs Hanson has been reluctant to accept personal care so far. She states that she can manage herself, however is unable to get out of bed herself and requires assistance from at least one staff and two staff for standing and transferring. Mrs Hanson is currently suffering from confusion due to UTI for which she is taking antibiotics. She has oedema to both legs which it makes it difficult for her to move. Mrs Hanson accepted personal care www.safeguarding4rochdale.com
Case Overview - Timeline 20thJanuary 2015 Mrs Hanson accepted personal care 21stJanuary 2015 A social worker from Rochdale Adult Social Care Social contacted the manager at the care home and was told Mrs Hanson was currently on anti-biotics for a urinary tract infection. The social worker noted on Mrs Hanson s Adult Social Care file that the case needed urgent allocation for a full care assessment to be completed. www.safeguarding4rochdale.com
Case Overview - Timeline 23rdJanuary 2015 A team manager from Adult Social Care telephoned the care home and asked how Mrs Hanson was. The team manager was told Mrs Hanson was appearing better physically but that she still needed support to go to the toilet. The team manager advised a member of the team would visit on Monday 26 or Tuesday 27January 2015. A district nurse from Pennine Care NHS Foundation Trust telephoned Tony and advised that his mother was reluctant to mobilise and had lost confidence. The district nurse suggested Tony contact the Falls Team when Mrs Hanson returned home. www.safeguarding4rochdale.com
Case Overview - Timeline 26thJanuary 2015 A support planner telephoned the care home manager and was informed that Mrs Hanson had a massive crisis of confidence due to a number of falls and she would not be going home for the foreseeable future as she was not physically fit and would not cope with her mobility at home. Tony wanted his mother to remain at the care home until she was fit to go home and an appropriate care package was in place. The support worker marked the file as no further action leaving the onus on the care home to contact Adult Social Care when Mrs Hanson was ready to go home. Mrs Hanson s case was still waiting to be allocated to a social worker in Adult Social Care. www.safeguarding4rochdale.com
Case Overview - Timeline A district nurse was present at the care home delivering urinary tract infection training. Following the training session the district nurse was approached by a staff member to give advice on Mrs Hanson s presentation of a urinary tract infection. The district nurse tested Mrs Hanson s urine and found the sample to have blood within it. The staff member also requested a further physical examination of Mrs Hanson. The staff member advised the district nurse that Mrs Hanson had refused care home staff to examine her or attend to her personal needs and staff were concerned about a spot that needed checking. On examination Mrs Hanson was found to have a grade 4 pressure ulcer on her left buttock. The district nurse requested staff to call an ambulance using 999. www.safeguarding4rochdale.com
Case Overview - Timeline The ambulance crew raised an adult safeguarding concern. Mrs Hanson arrived at hospital where it was apparent she was very ill. Tony and the medical staff agreed that a do not attempt resuscitation approach was in Mrs Hanson s best interest. 27thJanuary 2015 Mrs Hanson died in hospital at 04.25. www.safeguarding4rochdale.com
Learning Process Event date & time; Event i.e. what actually happened? Policy/Protocol/Practice Standard/Compliance i.e. what should have happened (including by whom); Relevant supplementary information; Missing information & gaps, omissions & breaches; Notable good practice; Contextual information & contributing factors to the above. www.safeguarding4rochdale.com
Learning event What worked well in this case and why? What did you/your agency do that you/your agency should have/not have done? Why? What could have been done better? What needs to change? www.safeguarding4rochdale.com
Lessons Learned The panel s lessons, which are reflected in its and the agencies recommendations, fall into five areas. The first is centred on the care home and its inability to provide a safe, dignified and caring environment for Mrs Hanson and its record keeping. The second reflects the need for commissioners to ensure that all care home places it commissions provide a safe, dignified and caring environment with good record keeping. The third is for Rochdale Safeguarding Adult Board to ensure it can identify potential safeguarding adult review cases in a timely manner and submit them for screening. The fourth is for Rochdale Adult Social Care s: allocation, record keeping, case closure and oversight. The fifth is for general practice and the lack of a physical examination and poor record keeping. www.safeguarding4rochdale.com
Recommendations That Rochdale Adult Social Care provides a written report on how commissioners quality assure care provision and what actions are taken to enable a safe level of care that is relevant to an individual needs. That the commissioners of care home places in Rochdale provide a written report to Rochdale Safeguarding Adult Board on the action it has taken to ensure the care home has taken effective remedial action that enables staff to identify developing pressure ulcers, provide appropriate preventative measures and have effective techniques for dealing with residents who are resistant to intimate care routines or positional change. www.safeguarding4rochdale.com
Recommendations That the commissioners of care home paces provide a written response to Rochdale Safeguarding Adult Board on what is being done to ensure record keeping in care homes is fit for purpose in that a resident s stay, including their qualitative experience, is accurately and fully recorded in the residents care plans. That Rochdale Safeguarding Adult Board satisfies itself that there is an effective process in place for identifying cases that have potential to be safeguarding adult reviews, including those where the coroner has issued a Regulation 28 Notice, and for forwarding such cases to the safeguarding adult review screening panel. That Rochdale Adult Care Services reports in writing to Rochdale Safeguarding Adult Boards the arrangements in place for recognising and responding to changing circumstances which impacts of risk assessments for people it is providing services to. www.safeguarding4rochdale.com
Three things. Critical thinking skills Recording What information is most important What might be left out What do I think How did I arrive at what I think What are my assumptions are they valid What do I not yet understand How can my agency help? www.safeguarding4rochdale.com
Six Honest Men I knew six honest serving men, They taught me all I knew; Their names are what and why and when, And where and how and who. www.safeguarding4rochdale.com
