Wigan Safeguarding Adults Board (WSAB) is required under section 44 of the Care Act to consider undertaking case reviews to establish whether there are lessons to be learnt from the circumstances of a specific case. Our approach is made of both:
- Discretionary case reviews or Brief Learning Reviews (BLRs)
- Statutory reviews or Safeguarding Adult Reviews (SARs) (as defined within the Care Act 2014).
Case reviews are undertaken to establish key learning and most importantly any actions required to improve policy, process or practice. Approaches that are based on the most appropriate methodology required and may include;
- reflective learning principles.
- whole system approach.
- Root cause analysis.
- Thematic Analysis.
- Specific quality assurance activity.
All reviews involve multi-agency participation to determine what individuals and agencies could have done differently that may have prevented neglect, abuse, harm or a death from taking place.
Why do we conduct case review?
The purpose of a case review is not to apportion blame, it is to promote effective learning and improvement to prevent similar issues occurring again.
A case review highlights key recommendations for system, practice, policy or process changes and actions are managed within the WSAB delivery group framework. These are analysed from both a local, regional and national perspective to establish key areas for local improvement, training or service delivery; these in turn inform the WSAB overarching strategy.
Safeguarding Adult Reviews
A key element of the learning process has been to publish our SAR case reviews via briefing documents (pre 2019 we published full reports) so that practitioners or other interested parties can access the learning themselves. In the case of SARs that the WSAB has decided not to publish, for transparency these are noted but with no additional briefing.
Brett began to struggle with his mental health in his early 20’s and was given a diagnosis of schizophrenia. Following two periods of inpatient care under mental health, sadly Brett took his own life in Spring 2018.
The main themes within the case are: Mental Health, Suicide.
Colin is an elderly man who was admitted to hospital in a poor state of health due to his care and support needs not being met by his informal carer following a failure of services to respond to concerns or to assess Colin's needs.
The main themes within the case are: Self Neglect / Neglect and Acts of Omission, Informal Carer, Pressure Ulcers.
Diane died as result of fire in her home. She was considered complex and was presenting to services with increasing medical needs, both physical and mental. Diane had a history of trauma and self-neglect, as well as ongoing concerns regarding self-neglect and hoarding, especially in relation to refusing care and support.
The main themes within the case are: Fire Risk, Self-Neglect, Learning disability, Trauma.
Helen was an elderly lady residing in a care home. Helen was found to have died following being trapped in the telescopic bed rails that were fitted to her bed. The bed rails had not been fitted correctly. A police investigation was completed; however, the CPS made the decision that no criminal prosecutions were being pursued.
The main themes within the case are: Neglect and Acts of Omission and Organisational Abuse.
David was an elderly man who was living with a number of chronic physical conditions, including Ischemic Heart Disease, asthma and COPD. David died in hospital in 2019 of natural causes following a rapid deterioration in his physical health and his ability to care for himself in his own home. This impacted on his wellbeing.
The main themes within the case are: Informal Carers, Self-Neglect, and Pressure Ulcers.
Una was a patient with the local mental health trust and her care coordinator groomed her, before starting a sexual 'relationship' with her from July 2015 to May 2016 which was exploitative, a criminal offence under section 38 of the Sexual Offences Act 2003 and a gross breach of his duty of care as a nurse.
The Trust and Police were aware and did not prevent the continued abuse. The response resulted in a breakdown in the therapeutic relationship and the Trust did not comply with duties to report the abuse via StEIS or with s117 MHA aftercare responsibilities. The Trust were unable to transfer her care to another Trust. Further areas of learning regarding the effectiveness of safeguarding enquiries within the context of organisational abuse and sexual offences, managing allegations against people in a position of trust, system oversight of patient safety and quality of care / access to justice for adults at risk are key areas of learning within this case review.
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Jayne was a middle-aged lady who had a schizophrenia diagnosis and who was not receiving any treatment or prescription for this condition. Jayne was supported by primary care with a diagnosis of Eczema and dry skin conditions for many years, these began to worsen in 2019. There is some question as the whether Jayne was able to follow her skincare plan as described. Jayne was referred and seen by dermatology but disengaged.
Jayne’s lack of self-care / self-neglect led to deterioration of her physical health. Jayne had an admission to hospital in March 2021 in which she received intensive care treatment due to low blood sugar. This followed two inpatient episodes in the proceeding year in which she presented with signs of self-neglect. Jayne was flagged by health professionals as potential self-neglect within all these hospital episodes. In the March admission there were further concerns regarding her welfare from numerous agencies with a concern raised re potential sexual abuse. This became a focal point of s.42 enquiries whilst Jayne was an inpatient. Police investigated this and no issues had been disclosed by Jayne therefore the Police and s.42 Enquiry were closed.
Jayne was discharged home with no onward support having declined social care following improvement in her physical function. A referral was made to the Community Mental health team whilst in discharge, they were not informed when Jayne returned home, and this was not followed up. As a result, Jayne was not seen by any agency between discharge and subsequent re-admission when she had deteriorating physical health. Jayne died with a diagnosis of Stevens-Johnson Syndrome. There appears to have been no offers of support regarding the informal care that Jayne's relative was providing, she reported struggling with this throughout this period. The system did not recognise or respond to a repeating pattern of poor self-care / self-neglect leading to physical deterioration and inpatient admissions, exacerbated by inconsistent take up of community service offers.
The main themes of the review are: Self-Neglect, Mental Capacity and Safeguarding Processes
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