Gateshead Safeguarding Adults Annual Report 2022/23

Gateshead SARs

The SARCC Group is responsible, on behalf of the Gateshead SAB, for statutory SARs introduced by the Care Act 2014. All reviews and enquiries are reported back to the SAR Group for scrutiny and challenge. Learning from reviews is fed into the Quality, Learning and Practice Group when there are specific actions or learning that needs to be taken forward.

During 2022/23 the SARCC received 7 Safeguarding Adult Referrals, none progressed to mandatory SAR:

Referral 1

The young man was 26 years of age when he died in the Freeman Road Hospital in Newcastle. He had significant health issues and complex needs, having suffered significant physical harm following an overdose in 2014, this resulted in kidney and brain damage. He had a diagnosis of Asperger's, as well as psychosis, Cluster B personality disorder traits, and a learning difficulty.

He was cared for by family members and due to not previously tolerating social situations well, including hospital visits, he received kidney dialysis at home. The family had been provided with carers assessment in the past.

He was admitted to the QE hospital on 13th March 2022 and subsequently transferred to the RVI in Newcastle on 19th March 2022 with scurvy, severe malnutrition and emaciation which required intensive care treatment. Significant resistance and behavioural issues made provision of essential ongoing medical treatment complex.

On 20th March 2022 a DNACPR was put in place, and he was transferred from the RVI to the Freeman Hospital in Newcastle. He passed away on 14th April 2022 with his Mam and sister present.

He had been the subject of a S42 enquiry in 2020 following admission to hospital. He had been brought into Freeman Road Hospital unconscious in a wheelchair by his sister. He was noted to be unkempt with dirty hands and fingernails responding only to pain. He was Hyperkaliaemic and suffering from septic shock he was taken immediately to ITU.

This S42 enquiry was closed as it was felt that his family had been anxious about the risk of C-19 infection in hospitals. The family had contacted professionals to seek support and appeared to be trying to find the balance between seeking help and taking his previous wishes and views into account to remain at home or to go to a hospital that he trusted. Their actions appeared to be borne of anxiety and fear and possibly a lack of understanding about how poorly he was, rather than from an intent to prevent access to medical treatment or to cause harm. A robust risk management plan was provided for the family to follow.

Partner agencies were asked to provide information on any contact they had with this young man or his family to enable the SARCC group to consider if the actions from the previous S42 enquiry were taken forward, if they were reasonable and achievable and if partners worked in his best interests around his mental capacity in relation to medical treatment, attendance at hospital and medical appointments.

SARCC recommendation: The case did not meet the criteria to progress to a mandatory SAR as there was no evidence to link abuse or neglect to the death. The group felt that there was learning which could be taken from the case in relation to mental capacity and the use of multi-disciplinary meetings. The learning review is being drafted by partners and the actions will be progressed by the QLP Subgroup.

Referral 2

See Learning from SARs and other Enquiries in Key Activities 2022/23.

Referral 3

No further action.

Referral 4

This lady was found deceased in her flat by her father on in September 2022. She had a history of chaotic substance misuse, self-neglect, lack of self-care resulting in deterioration in health, a frequent caller to emergency services and non-engagement in treatment and care. She was 43 years old.

She had suffered a stroke in the past and struggled verbally to communicate and move around physically, she had mental health problems and several physical illnesses. She had a package of care and was open to the Mental Health team at the time of her death. She was known to be a frequent caller to emergency services.

SARCC recommendation: See Referral 7.

Referral 5

This lady passed away at the age of 47, following a cardiac arrest. She had physical disabilities resulting from an injury 20 years previously, which eventually resulted in her right leg being amputated below the knee. She was wheelchair bound, had a prolapsed disc in her back, could not weight bare, used equipment to aid her mobility, she had contracted septicaemia in her hands and feet in November 2020 and had her right hand amputated at the wrist.

She lived with her elderly mother who was her main carer in a two-bedroom bungalow, although it was noted that rehousing to a larger property was necessary to meet her long terms needs.

The case was discussed at the SARCC group with the main areas of concern being around the lady's mental capacity and her ability to understand the impact of her refusal of care on her health and her mother's ability to adequately carer for her. There was some evidence of self-neglect but due to the lady's capacity it was deemed to be her choice to refuse personal care.

SARCC recommendation: The case did not meet the criteria to progress to a mandatory SAR as there was no evidence to link abuse or neglect to the death. The group felt that there was learning which could be taken from the case in relation to mental capacity, self-neglect and the ability of carers to provide the level of care necessary for relatives. The learning review has been drafted by partners and the actions will be progressed by the QLP subgroup.

Referral 6

This was a 46-year old women who died at the Queen Elizabeth Hospital. She had a learning disability and was known to GHFT, CNTW and Gateshead Adult Social Care.

The case was referred to LeDeR (Learning from lives and deaths - people with a learning disability and autistic people), as the concerns raise related to a single agency and the death was not as result of abuse or neglect. The findings from the LeDeR have not yet been published.

Referral 7

This gentleman was found dead in his home in October 2022 he was 51 years old. He had a history of alcohol dependence. He was diagnosed with acquired brain injury from his alcohol use.

He had been living in Scotland, and while there Edinburgh Council had guardianship of him and he was placed in Abbeymoor Neurological Care Centre, Gateshead under a Deprivation of Liberty Safeguard (DOLS). He asked the court to rescind his DOLS. The DOLS medical assessor assessed him in May 2022 and deemed him to have capacity, with no cognitive deficits. They could not find any symptoms of a major medical disorder, noting he displayed some traits of Cluster B personality disorder (specifically narcissistic). Staff at Abbeymoor, the BIA, and the DOLS doctor all agreed he had capacity to make decisions about health, welfare, and residence, and said "any unwise decisions should be interpreted as a result of personality traits rather than as the consequence of a mental illness."

He consistently refused to accept any form of support to address his alcohol use. At the time of his death, professionals had not been able to persuade him to accept the referrals into treatment services and he had not managed any prolonged periods of abstinence since his discharge from a care setting in May 2022, his level of alcohol abuse had been described as a considerable risk to his health.

SARCC recommendation: It was agreed that Referrals 4 and 7 should form part of a thematic review into vulnerable dependent drinkers. This work is being progressed via a task and finish group who have agreed the terms of reference for the review. An independent author will be appointed, and this work will feed into the development of services specifically to support vulnerable dependent drinkers.