Safeguarding Adults Review: Mary

Background

Mary was a 68-year-old woman who had diabetes and was registered blind. She was previously a registered carer for her father and brother.

She did not have much family involvement for the last few years of her life. She had moved out of the family home since the death of her father and the brother for whom she used to provide care for was now in supported accommodation.

Mary resided in temporary accommodation and was known to a charity in Islington that she attended.

A volunteer from the charity contacted the police as Mary had not been seen for a few days. Police carried out a welfare check and found Mary deceased in her home. They found the house in an unkempt manner with sticky floors, kitchen was cluttered and dirty and her bed was covered in belongings which were not suitable for sleeping. There was little food in the cupboards at home. The case was referred to the Safeguarding Adult Review (SAR) subgroup for further exploration.

Safeguarding Adults Review

The SAR subgroup recommended that a multi-agency partnership learning review to be carried out involving all the agencies that were involved with Mary as a way of learning from this case and improving practice.

Learning points

Patient Recording systems

Based on health partners patient recording systems it was assumed that Mary was registered with a GP. The review found this was not always the case.

• Does the health system have a clear pathway to assist people with care and support needs to register with a GP?
• Does your service ensure any record keeping is up to date and there is clear governance in place to check and escalate relevant information?

Collaborative working

Partners had individually highlighted positive work with Mary individually but had not communicated well with each other for a holistic view on how Mary could have been supported.

• Does your agency hold multidisciplinary meetings to support an individual? Remember- anyone can call an MDT meeting.
• Do you escalate any concerns where there are increased social admissions for someone?
• Do you share your concerns with other agencies to assist collaborative working particularly at frontline?

Working with services

Mary had been offered support from a range of services which she often declined.

• Does your agency consider exploration of executive functioning and complete a comprehensive risk assessment?
• Have you considered collaborating with community and voluntary agencies who sometimes have a better rapport with people?

Accessibility needs

Mary was registered blind and had told one of the professionals that she missed an appointment as she could not read the appointment letter that was sent out.

• Do you explore alternative communications methods to better engage with people with varying needs?
• Does your agency share relevant information about someone’s specific needs like this with other services to support their work with individuals?

Contact

If you are worried about someone who may be at risk of abuse or harm, call the Adult Social Care Integrated Front Door Team on 020 7527 2299.