Adult Safeguarding Learning
Resource
Anna review
Anna died in August 2022 at the age of 86 in hospital after a call was made to the ambulance service.
Anna had involvement from Primary care, community nursing and had a package of care in place (along with other agencies involvement). However Anna did not have any contact with primary care in the recent months prior to her death.
There is generic learning for all agencies and please do share this with primary care as and where appropriate, however there was nothing specifically just for Primary care.
Findings :
Information sharing and communication – In 2016, Tilia was described as ‘having care and support needs’, but there were no further assessments of these needs, or discussions around mental capacity. It was only after Anna’s death that an assessment was undertaken, which revealed significant health conditions which had not been raised during the review, or shared in safeguarding meetings
Translation and interpreting services – There was no professional challenge about the continued use of a family member even when concerns had been raised about the accuracy of translation. A reminder for agencies to use interpreters services and not relatives as an interpreter.
Cultural and Unconscious Bias: The impact of racial bias and lack of insight about cultural competence was raised forcibly by practitioners at the learning event – ‘if this was a white family would this have happened?’ Desensitisation to Anna’s situation and presentation prevented curiosity about how Tilia was providing care. Concerns about the smells coming from Anna’s flat were not reported because of ‘fears’ that this might look like racism, and the care providers took Anna’s ‘smiles’ as agreement. We now know how Anna was screaming and banging on the wall to no avail.
Taken from the report:
7.6
‘Tilia had not seen her GP for medication for these health conditions since 2019. It is highly possible that this had an impact on her health and wellbeing and her ability to provide care. In addition, Tilia had not been able to ensure that her mother had regular access to her GP since 2019. The meeting between the author and Tilia highlighted quickly that Tilia did not appear to have an appreciation or understanding of either her mothers’ health needs or her own, other than to say that her mother was ‘poorly’. If this information had been known and shared it might have had implications for her support of her mother and might have prompted an increased level of concern about her ability to provide care . It would also have been an opportunity to work with Tilia to access support for her own health needs. Clearly, there was no sense of curiosity or even compassion from numerous services about Tilia and how she was managing her life. Meeting with Tilia was a sad moment as it demonstrated that she had been invisible and as stated above she was not able to articulate an understanding of what had happened or her own needs.’
This is not in the report, but it is noted form information collated that the GP made contact by letter and phone in 2021 regarding covid vaccine and patent didn’t attend her appointment.
Anna SAR final report (southampton.gov.uk)
Anna 6 step briefing (southampton.gov.uk)
Gainbir
Gianbir was a 55-year-old man of Asian heritage who lived with his brother in private housing.
South Central Ambulance Service (SCAS) were called to home address of Gianbir in early December 2021 by a family member/carer, reporting that Gianbir was having difficulty breathing and was very unwell. On SCAS attendance the crew noted significant concerns regarding the environment and Gianbir, was very unwell. There were considerable concerns about the extent of Gianbir’s unkemptness and that there was no internal door handle on the door which would allow Gianbir to leave if he needed to. The family member/carer could not give any information pertaining to Gianbir’s past medical history, allergies etc. although they identified themselves as his primary carer.
There is generic learning for all agencies and please do share this with primary care as and where appropriate, however there was nothing specifically just for Primary care.
Findings:
Culture and Language – Services continue to use family members as interpreters. This means that the individual is not always spoken with alone and assumptions can be made as to the views of that individual. It also places family members in a difficult position as they might not have the language capability to fully understand medical explanations.
Lived Experience: Think Family – There was limited understanding of the lived experience of the two individuals living in the home
Professional Curiosity in Safeguarding Adults – The Gianbir SAR has raised questions regarding how professionals recognise and respond to indicators of self-neglect
Gianbir SAR final report (southampton.gov.uk)
Gianbir 6 step briefing (southampton.gov.uk)
