7 minute briefings

7 minute briefings are based on a technique borrowed from the FBI. Learning for seven minutes is manageable in most services, and learning is more memorable as it is simple and not clouded by other issues and pressures.

Their brief duration should also mean that they hold people’s attention, as well as giving managers something to share with their staff. Clearly the briefings will not have all the answers, but it is hoped that they will act as a catalyst to help teams and their managers to reflect on their practice and systems.

The expectation is that team leaders will present briefings to their staff, on a regular basis.

Adult abuse or neglect

Do not ignore it.

  • call 999 in an emergency
  • Telephone: 0161 217 6029
  • Minicom: 0161 217 6024
  • Out of  hours: 0161 718 2118
7 minute briefing: Elizabeth

Background

Elizabeth was 87 years old. She lived in a one-bedroomed first floor flat.

Her 2 sons spent extended periods of time living with her and they all had a history of alcohol excess. In March 2015, Elizabeth was diagnosed with alcohol related dementia and she was known to specialist services. She did not reduce her alcohol intake and on some occasions did not attend pre-arranged appointments.

Elizabeth may have been neglectful of her own health needs at times which could have been induced due to alcohol related dementia impacting her perception of her own health needs.

Safeguarding concerns

An ambulance attended the flat and found Elizabeth in a soiled bed and unable to mobilise. A number of people, including her son appeared to be intoxicated at the flat. Elizabeth was taken to hospital and the ambulance raised a safeguarding concern.

Elizabeth was examined and was found to have fractures and bruising. She also appeared to have suffered a stroke and had an acute kidney injury. Elizabeth’s son states she fell 4 to 7 days before the call but without any medical treatment, and since then, she had been in bed immobilised. There were previous concerns relating to;

  • financial exploitation
  • the buzzer to Elizabeth’s flat being disconnected
  • her compliance of medication

It was reported by professionals that Elizabeth appeared nervous and shaky when in the presence of her son.

Financial exploitation

There was a lack of consideration of both sons coercive and controlling behaviour as a factor in her decision making. Opportunities were missed to support Elizabeth with the concern of capacity, best interest and financial exploitation, through the lack of professional curiosity and with professional challenge to both sons of the concerns. There was a lack of co-ordinated single and multi-agency action to address the ongoing allegations of financial impropriety.

Alcohol misuse

Elizabeth was advised to reduce her drinking, or preferably abstain and advised that some of the effects on her cognition may be reversible. She said that she did not want to stop drinking alcohol despite advice from professionals and support from her son. Good practice by professionals was evident.

Information sharing and multi-agency working

A stronger focus on multi-agency working would have strengthened an understanding of Elizabeth’s daily lived experience and enabled a more robust approach to information sharing and the commitment to safeguarding her.

Communication between agencies would have enabled professionals across services to discuss Elizabeth’s needs and risks and jointly manage them. Capacity assessments, including consideration for fluctuating capacity were not always conducted in the context of other vulnerability factors and a multi-agency discussion would have been beneficial.

Other risk factors

There was a lack of consideration about the potential risks to Elizabeth from both her sons whilst intoxicated, and when staying with her, acting as her carers. Neither son appears to have been offered a carer’s assessment or to have received carer’s allowance.

Safeguarding process

Neighbourhood services now operate a model where multi-agency working is at the heart of complex cases and the new model is co-located which affords greater opportunities to work together and share information in real time.

There is a new liaison forum between the neighbourhood team and housing, in which cases like this would now be assessed.

Adult Social Care has a new process to make sure greater professional presence at the first point of contact. The aim is to make sure that the public and professionals get the right advice, information and response in a timely manner. This means the risk and safeguarding issues are identified and addressed at first point of contact.

7 minute briefing: Mrs Grant

Background

Mrs Grant was a 93 year old who lived in a Nursing home. She was diagnosed with dementia and was very frail. She had a do not attempt cardio pulmonary resuscitation (DNACPR) in place. Her health had
deteriorated in the weeks before her death and she required assistance to eat and drink.

On the day she died, Mrs Grant was being fed by a health care assistant (HCA). The HCA noticed she was choking and having difficulty breathing. The HCA raised the alarm and the registered nurse (RN) attended the scene and an ambulance was called,

The cause of death was hypoxia, otherwise known as a deficiency of oxygen, followed by aspiration of food own health needs.

Concerns

 

  1. Communication: the RN did not respond appropriately and left the HCA alone with Mrs Grant who was choking. This was because they went to speak to the operator in another room as the phone was fixed in the office. The RN also did not identify at the time that she was a nurse.
  2. Paramedics arrived and found Mrs Grant struggling to breathe, she subsequently went into respiratory arrest. The paramedic sought immediate advice by radio from an advanced paramedic. The on scene Paramedic did not share that Mrs Grant was choking, hence advice was given to cease resuscitation.
  3. Risk assessments: on admission Mrs Grant was assessed for choking and the assessment states she preferred not to wear dentures whilst eating. The risk assessment scored low. However, they were not reviewed monthly and updated accordingly, which left her at risk.
  4. Risk assessments: on the day she died Mrs Grant struggled to swallow medication. Although this was not the cause of the choking incident staff did not review or update the risk assessment to assess whether the risk of choking had altered
  5. DNACPR and MCA: while the GP followed guidance and unified policy relating to DNACPR, the GP made the best interest decision based on conversations with the son via email, and without a face to face visit with Mrs Grant.
  6. Equipment: when Mrs Grant started to choke the paramedic tried to use 2 of the home’s suction machines to clear an obstruction in her airway. Neither machine was working. This meant there was a delay while the paramedic fetched a suction machine from their vehicle quipment
  7. Equipment: the oxygen cylinder from the ambulance was empty. It appears the reason the cylinder discharged was because a valve may have become caught on the bag it was contained in.
  8. Staff training: induction training had not been fully completed by the HCA or RN, which included first aid training. The RN did not adhere to basic life support training which include responding to choking.

Learning

  1. Communication: the person making any 999 call should ideally be in the same room as the resident who needs help. This avoids messages having to be relayed and shortens the line of communication. RNs are required to act with professional standards within the nursing code of conducts.
  2. Paramedics seeking advice from other professionals should make sure they provide all the relevant information to enable the relevant advice to be provided.
  3. Risk assessments@ all nursing and residential homes need to make sure that all risk assessments are completed, reviewed and updated as indicated within the risk assessments.
  4. A review of risk assessment should be immediately undertaken in the event of a change of circumstance/health.
  5. GPs who make a DNACPR decision should see the person prior, in order to assess their physical health and mental capacity in relation to the decision.
  6. All equipment in care and nursing homes should have a written maintenance and testing policy, and an audit log of the test results.
  7. Emergency staff need to be aware that under some circumstances, oxygen cylinders may be inadvertently discharged which will lead to an empty cylinder.
  8. Nursing and care homes need to have excellent induction programmes so that new staff are competent, and feel confident, in dealing with emergencies. Nursing homes also need to be assured that RNs have relevant training, registration and revalidation requirements are in place.

What’s next?

Nursing and care homes need to have excellent induction programmes so that new staff are competent, and feel confident, in dealing with emergencies. Nursing homes also need to be assured that RNs have relevant training, registration and that revalidation requirements are in place.

7 minute briefing: Ann

Background

Ann died in September 2017 in Stepping Hill Hospital, aged 77 years. The cause of death was Sepsis and bronchopneumonia. Ann moved into residential care in 2000 due to her mental health deteriorating. During this time she remained fairly independent. Ann lived for a cigarette and a cup of tea and whilst in residential care she started to spend time in her room and would not go and speak to people.

Ann had a diagnosis of Chronic Schizophrenia. She suffered from several issues, including self-neglect, which was linked to her mental ill health. She had fixed ideas and delusional beliefs, and her symptoms related to this included paranoia around drinking water being poisoned.

Ann had daily rituals that included sprinkling urine around the room and over herself as she believed it acted as a protective measure. In the last few months of her life her level of self-neglect increased, and she started to smear faeces around the walls of her room.

Diogenes Syndrome is also a disorder characterised by extreme self-neglect.

Safeguarding concerns

On occasions, compliance with medications and other treatment was compromised and Ann would refuse treatment. Ann would present self neglect behaviours which would impact on her personal hygiene.

Care staff would encourage to support Ann with bathing and showering, which on occasions would lead to threatening and confrontational behaviour, both physical and verbal to both residents and care staff. At times, Ann was extravagantly psychotic, and this manifested itself in delusional beliefs, in which she would present rituals involving excreting and urinating in the home.

Ann would refuse to attend or accept medical tests, interventions like scans and this would cause great concern to staff. Ann’s emotional behaviour would fluctuate and care staff would at times
struggle to engage to support Ann.

Placement

The Care Home provides care for up to 14 adults. The home was last inspected February 2017 with an overall rating of good. The CQC report states the service was well-led, although further improvements were required.

Accommodation is provided on 3 floors, accessible by 2 stair lifts. There are 12 single bedrooms and 2 bedrooms that have the capacity to be used as shared rooms. Ann occupied a bedroom on the lower ground floor. The room had a sink and Ann had the shared use of a bathroom and lavatory.

The home has a lounge/dining room and a conservatory which is currently used as a smoking area as well as an outside garden to the rear of the property.

Findings

Ann was a resident at the care home from 2000 and she was happy there. She regarded it as her home. In February 2007, Ann was referred to the Older People’s Mental Health Services based in
Stockport. She would frequently decline to see a GP. However, arrangements were in place for GP’s to undertake a ‘virtual’ round of the care home. There was limited face to face contact between Ann and her GP.

Non-compliance of prescribed antipsychotic medication, which later resulted in a decline of Ann’s mental health.

During the 14 years that Ann was open to the Community Mental Health Team she was visited by 13 different CPN’s. She had a history of self neglect and believed food and drink was contaminated.

Staff appeared to tolerate Ann’s actions and developed strategies to work around her unusual behaviour such as waiting while she was out to enter and clean her room.

There were 2 missed opportunities for professionals from 2 different agencies to share information, which would have led to the care homes concerns being escalated.

There were references for the need to consider a DOLS and ‘Best Interest’ meeting which suggests concerns Ann may have lacked capacity. However, no record of any mental capacity assessments.

No direct concerns relating to Ann were raised with Adult Safeguarding Quality Service (ASQS) either by the home manager or other visiting professionals.

3 safeguarding alerts were raised with Adult Social Care (ASC) at level 4/5 concerning events at the care home. One of these was made by NWAS in respect of following Ann’s most recent admission to  hospital. The other 2 referrals related to other residents.

The Care Home did not appreciate that the Adults Safeguarding process could have been used as a way of escalating any concerns. Ann was found in a collapsed state in her bedroom at the care home. An ambulance was called and she was admitted to Stepping Hill Hospital.

Learning

  • Information sharing is key. 
  • Consistency and continuity of workers is imnportant.
  • Face to face engagement with residents and GPs can influence a formal assessment by the GP.
  • Clear and explicit written records will assist communications between staff and agencies.
  • A multi-agency approach ensures a robust plan that can be shared and understoood by all agencies.
  • To understand the urgency of a caller’s need and ensure appropriate and timely responses are in place.
  • Before moving to ‘Best Interests’ or DOLS, a capacity meetings, an assessment must be carried out and recorded in line with MCA 2005.
  • Staff to have a good understanding of the safeguarding processes and to escalate concerns, including the use of Stockport Adult Social Care Safeguarding Referral Process.
7 minute briefing: Mrs Rogers

Background

Mrs Rogers was one of 4 children who was born, brought up and educated in Stockport. She married at 18 years of age and had 4 children. Mrs Rogers’ husband died in 1997 and until 16th July 2015 she
lived alone in a ground floor maisonette with support from her family.

Mrs Rogers was admitted to hospital having fallen at home. She was diagnosed with a fractured pelvis and discharged home the same day. One week later Mr Rogers had encountered a fall in her bathroom, a home visit was arranged the following day by a physiotherapist and a nurse.

No additional needs were identified at this time. 3 days later Stockport Adult Social Care (ASC) received a call from a family member reporting Mrs Rogers was unable to cope at home. Mrs Rogers was
provided with 2 morning calls from carers, this fell short due to a lack of service provision within the market. Mrs Rogers was then admitted to a Rapid Response Bed in a Care Home. Mrs Rogers health deteriorated over the 12 days whilst in the care home and she was taken to hospital.

Families safeguarding concerns

In the week before Mrs Rogers’ death on 7th August 2015, the family shared concerns at the care home that Mrs Rogers health had deteriorated. The family felt their concerns were ignored:

  • on 7 August 2015 the need for an ambulance was not recognised in a timely manner
  • the family said they visited Mrs Rogers on several occasions whilst in the care home and found her in her own faeces
  • the family reported that no rehabilitation had been undertaken with Mrs Rogers during her residency at the care home
  • the family said that Mrs Rogers had requested that only female staff provide care but after 2 days male staff were providing care to Mrs Rogers

Placement

The care home Mrs Rogers was placed at is a purpose built facility offering dementia, nursing, residential and end of life care using a mixture of care and nursing beds. The nursing beds have 24 hour nursing cover, whereas care beds do not.

The hub bed scheme was designed to prevent admissions to hospital and to enable people to return to their homes when able.

Due to a lack of service provision, Mrs Rogers was admitted to a Hub bed scheme because her mobility had deteriorated and she was unable to move or transfer without assistance. Mrs Rogers accepted she needed short term residential care to help her recovery. The move to the care home was also supported by her family who felt she need rehabilitation before returning home.

Review

A Safeguarding Adult Review (SAR) was held in in Oct/Nov 2016 to identify how agencies worked together and to learn from any lessons.

View the report of the SAR.

Findings

Mrs Rogers died from peritonitis and a perforated bowel that had not been diagnosed or treated.

Her mobility needs became more acute and Adult Social Care (ASC) provided twice daily visits. Following an assessment this increased to 4 visits daily.

A 4 visit package could not be provided. Therefore, ASC commissioned an emergency placement in a hub bed at a care home.

Mrs Rogers experience as a resident was described by her family, as very poor. The family felt there was no dignity shown to Mrs Rogers, or her care.

Recommendations

SSAB will have:

  • a SAR process that identifies potential safeguarding adult reviews at the earliest opportunity
  • assurances of the timeliness of assessments in providing of adaptive equipment
  • assurances that Care homes have an emergency admissions procedure to ensure resident’s needs are assessed
  • assurances that Care homes will have appropriate access to GP medical information as soon as possible
  • assurances of good record keeping and sharingof information between professionals in care homes
  • medication policy will be reviewed
  • agency staff are committed to engaging with SARs in accordance with Section 45 Care Act 2014

Reflection for practice

  • ASC have established a new joint enhanced quality team to improve professional standards
  •  ASC have established a new joint enhanced quality team to improve professional standards
  • ASC will go into care homes where there are issues or concerns about quality or safety
  • ASC will expand the range of its work and provide support for care homes
  • Stockport CCG will conduct medication audits
  • Stockport workforce development will provide workshops in prescribed medicines
  • Stockport workforce development will continue to work with providers to reinforce the importance of dignity in care
  • ASC will continue with annual monitoring visits
  • ASC to promote the dignity in care accreditation with Care home providers with follow up checks to who has enrolled
7 minute briefing: Annie and Stanley

Background

Annie was a 37 year old woman, a mother of 2, who died from sepsis relating to pressure ulcers as a complication of malnourishment and self-neglect. It was not clearly understood why she had stopped eating. She had a history of alcohol misuse as well as mental health needs. She was a previous victim of domestic abuse, with a decline in self- care, when she lost her job and following an accident, causing damage to herself.

She had also been diagnosed with breast cancer. She had 2 sons who had previously been on child protection plans who had gone to live with maternal grandparents. The younger son, aged 15 moved back to care for Annie when his grandparents became unwell themselves. The second son, age 18 moved out of the family home to live with his girlfriend.

Families safeguarding concerns

Annie had self-discharged from hospital 6 months before her death. Professionals dealing with her did not always seem to understand the complexity of her social circumstances. There was a tendency to accept at face value what she was saying. Sometimes people involved in her care demonstrated a lack of professional curiosity and as a result did not really understand the true situation. For example, although it was recognised that she was not eating, it was not clear why she was not eating. She would sometimes not engage with health services and would often not allow services to access her home.
At this point, a safeguarding concern could have been raised and a holistic assessment completed to address the needs of both mother and her youngest son.

Findings

  • Annie was an independent person who was reluctant to accept help or support.
  • She had experienced difficulties with her physical and mental health needs and these were exacerbated by the use of alcohol.
  • Agencies involved with Annie did not complete a capacity assessment.
  • Services assumed Annie had capacity and that she chose to make unwise decisions around eating and drinking.
  • As Annie’s physical health deteriorated and her self-neglecting behaviour increased, there was evidence to suggest agencies did not work together to reassess the family’s needs.
  • Annie’s bedroom was unkempt and evidence of poor condition.
  • Annie’s tenancy was compromised due to rent arrears, although support was offered and accepted for help to set up the new family home.
  • Concerns by school were raised suggesting the boys were unkempt and malnourished.
  • Consent for CAF not given.
  • There was a lack understanding to Stanley’s needs, particularly in relation to caring for his mother, rather than seeing him as a child in need of protection.
  • School supported Stanley to cope with home situation and focused on his needs.

Learning point: self-neglect

  • Some services did attempt to offer support although when support was refused, persistence and professional curiosity could have been explored.
  • Some services did attempt to offer support although when support was refused, persistence and professional curiosity could have been explored.
  • Frank and open conversations with service users about their choices being made and the impact on others is to be supported, particularly when related to children, and adults at risk
  • Training and supervision to facilitate such conversations must take place to ensure positive outcomes are achieved.
  • If a person raises concerns for us, won’t work with us, question why not and try to find a way to change this.
  • Escalation is a key learning point and guidance for practitioners can be found here.
  • If high risk cases are recognised early then collaborative working with partner agencies is vital to ensure joint risk assessment and planning is in place. This approach would allow early and effective identification of risk, improved information sharing, joint decision making and coordinated action.
  • Stockport requires a Multi-agency self-neglect policy – this has since been implemented and can be found here.
  • 6 full day training sessions have been launched throughout 2019, and agencies can access the training via Stockport councils learning pool.

Learning point: undertanding carers agenda

  • Consider the impact on a child being a carer to a parent.
  • Consider the impact on a child being a carer to a parent.
  • Consider involving carer support organisations for carers from all ages and backgrounds.
  • Consider whether it is appropriate to use a child carer to convey information to and from a possible adult at risk or with someone with vulnerabilities.
  • Practitioners working in Stockport with children and young people are reminded of the importance of hearing the young person’s voice – and ensuring it is neither missed nor given less credence as a result of the strength of the voices of adults around them.

Learning point: mutli-agency working

  • Practitioners are urged to seek support and supervision early, and with management oversight when involved in such complex circumstances so that an allocation of time and resources are available to support this.
  • Practitioners are urged to seek support and supervision early, and with management oversight when involved in such complex circumstances so that an allocation of time and resources are available to support this.
  • It is important that consideration be given for involvement from all agencies including mental health services, as seeking that support in children’s safeguarding is vital.
  • Safeguarding issues span across generations – the Think Family approach, is a significant area of focus, particularly with services working across boundaries and in partnership within adult and children’s services. This approach is important to Stockport in helping agencies to enable practitioners to work holistically with families as a whole.
  • Stockport will embed a strategic approach to Strengthening Families and Communities as part of the Council Plan 2018-19, with a view that restorative practice is culturally adopted to ensure that practitioners understand the need to work with whole families, not just individuals.

Further learning

Communication methods: it’s wise to explore the individual’s preference from an early stage, to ensure a dialogue that suits the adult, young person and the family. Further guidance can be found in the self-neglect practitioner’s guidance.

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