Learning, Action and Accountability

Hampshire Safeguarding Adults Board

Learning, Action and Accountability

Adult D

Adult D was physically frail and his wife had a severe dementia. The couple were supported by the community nursing team and the community mental health team. The couple were monitored via the primary care led ‘virtual ward’ process as people highlighted as at risk of hospitalisation. Adult D was the primary carer for his wife. Her health records stated that she needed 24/7 care and that she was ‘not fit’ to remain at home. She had been assessed as lacking capacity to make decisions in respect of care and treatment. No power of attorney was in placer. The couple self funded a domestic care package involving 3 visits daily from a local care provider. Adult D died in a house fire at his own home in 2016. Initial findings of the fire investigation indicate that the fire was a result of a human act, through ignition of bedding using a naked flame. A summary of the professional learning is summarised below:

Professional Learning

• In the case of self funders, a more assertive approach on the part of the local authority may be needed in terms of access to and assessment of someone lacking capacity being care for by a 3rd party.

• The Care Act safeguarding duty is not negated by a 3rd party’s refusal to engage or provide access to the person at risk.

• Given Adult D’s wife’s lack of capacity around care and support decisions, the involvement of an advocate to represent her views and to promote best interestsdecision making would have been helpful.

• A capacity assessment on Adult D should have been completed and he should also have been offered a carers assessment.

• All professionals should follow their agency’s policies and guidance around the management of refusal of support or disengagement. The approach used should include an appropriate contingency plan and escalation process to move the case into the multi agency arena in circumstances requiring rapid resolution.

• A multi-agency approach in this case was hindered by the lack of an individual assessment of the care and support needs (and risks)of each adult and the development of a multi-agency action plan to address these.

• Use of the 4LSAB Multi-Agency Risk Management Framework may have been helpful in this case – discussion highlighted limited awareness about the existence of this Framework.

• Clear, contemporaneous record keeping is essential.

• Health professionals would benefit from easier access to GP and community health record systems.

• A mechanism to identify and improve the visibility of the ‘critical few’ services users on case loads considered to be at high riskwould be helpful. Such as mechanism already exists via the 4LSAB Multi-Agency Risk Management Framework.

• Multi-agency awareness raising and training on 4LSAB Multi-Agency Risk Management Framework needs to take place.

• A fire safety referral to Hampshire Fire and Rescue Services should have been made in this case. All professionals need to ensure fire safety needs forms part of their core care and support needs assessment process.

• Referrals can be made to Hampshire Fire and Rescue Services for advice and guidance about individuals at risk of fire. Where possible, Hampshire Fire and Rescue Services recommendations should be embedded in all care plans as the gold standard.

Learning, Action and AccountabilityMarch 2017