Adults who self-neglect
Learning from serious case reviews and safeguarding adults reviews
There is some excellent practice, locally, regionally and nationally in social care and in health care.However, how do we understand failures in social care and health care, such as have happened in some NHS Trusts and some establishments offering residential and nursing care?Do we see failures in individual and/or systems terms?Are our systems rather like computers, vulnerable to infection by a virus? Which viruses?Who or what might be the equivalentof Firefox?
Practitioners and managers may collude in departing from best practice;Absence of challenge to unlawful & unethical practice – hostility towards whistle blowers and service users who complain;Ethical codes do not ensure best practice;Abusive practice across social (care) work;Reinstatement by Care Standards Tribunal of social workers – mitigating factors in inadequate supervision, chaotic departments, lack of supervision and management action (LA v GSCC ; Forbes v GSCC );Lack of managementoversight and action;Governance oversight is variable.
lack of self-care – neglect of personal hygiene, nutrition, hydration, and health, thereby endangering safety and well-being, and/orlack of care of one’s environment – squalor and hoarding, and/orrefusal of services that would mitigate risk of harm.A variety of key episodes – fire deaths, drugs and alcohol abuse, infections from poor tissue viability, impact of mental distress or learning disability, untreated diabetes …
What is the nature of the self-neglect cases reviewed through SCR/SAR processes?What themes emerge from the SCRs/SARs and how do these add to understanding about professional intervention in cases of self-neglect?How many and what kind of recommendations are made by SCRs/SARs and to which agencies are they addressed?
152 Local Authority and Local Safeguarding Adult Board web pages reviewed.Personal contacts with Independent Chairs & Board Managers.66 SCRs/SARs/learning reviews obtained, not all published.Other SARs/learning reviews known to have been commissioned and yet to be completed.Quite a process of discovery with implications for learning and service development.
Key characteristics of each case (n=62): gender, ethnicity, age, domestic living status, disability, details of agency involvement;Key characteristics of the SCRs/SARs (n=62): publication, length, whether self-neglect comprised a central dynamic, number of recommendations, availability of action plans;Frequency of recommendations in the SCRs/SARs for individual agencies and for LSABs where available for analysis;Themes extracted from the recommendations in the SCRs/SARs where available for analysis.
Thematic Analysis of SCRs
Published reports do not always give exact details of how the individuals concerned died.46% of the sample are male, 45% female 9% not known.26% of the sample were aged over 76; 9% of the sample were aged between 21 and 39; 24% between 40 and 59 and 14% between 60 and 75. Age unknown in 27% of the sample.Ethnicity was not routinely recorded in the reports.38 lived alone, 17 with family or friends, 5 in sheltered accommodation or care homes, 6 not known.
Type of self-neglect (n=58)
People may be unwilling and/or unable to address issues relating to self-care and care of their immediate environment.Lack of self-care (alcohol abuse, poor nutrition, neglect of hydration and ill-health) – 71%Lack of care of environment (squalor, hoarding, fire risk) – 45%Refusal of services – 76%All three elements – 41%
In available reports, self-neglect a central focus in 34, implicit in 13 & peripheral in 11. Material was unavailable for 8 reviews.Implicit = evidence of self-neglect but not named. Peripheral = self-neglect named but not the main presenting problem.Considerable variation in length: 5 – 108 pages.Similar variation (between 4 and 37) in the number and detail of the recommendations.Different approaches towards naming SCR author & independent oversight of process.Mixture of methodologies – traditional (IMRs, collated chronology and overview report; significant incident learning process; systemic exploration of key episodes and learning points.Mixed attitudes towards publication.
Recommendations to Agencies
(n=56) 82% contained recommendations for the SAB itself, with adult social care also targeted (64%).NHS commissioners (39%), Housing (29%), Mental health and acute care sectors (34%), Police (18%), GPs (23%)Some recommendations where it was not possible to identify the healthcare organisation (5 reports) or other agency (59%) charged with taking forward particular actions.Recommendations often directed simultaneously at a number of agencies and/or professionals, making audit of progress difficult. Occasional recommendations for national government, environmental health and ambulance services.Occasional recommendations for fire and rescue, ambulance services, environmental health.Only 20 SCRs (36%) contained action plans.
Types of Recommendations
Broad categories relating to procedures, best practice, SCR process, and staff training and support (n=56).Support – training (84%), supervision (50%)Procedures – develop guidance (77%), referral & assessment (77%), case management (41%), recording (57%), working together (59%), information sharing (43%)Best practice – relationship-centred (38%), engaging hard to reach (43%), mental capacity (50%), carer involvement, (30%) legal knowledge (25%)Hospital admission and discharge features occasionally., also auditingof cases.SCR process – action plan (30%), managing process (32%), using SCR (34%)
Themes from SCRs
Thematic Analysis – Adult
History – explore questions why; curiosityPerson-centred approach – be proactiveHard to reach – try different approaches, use advocates and concerned others, raise concerns, discuss risks, maintain contact, avoid case closureMental capacity – ongoing assessment & review, guidance for staff regarding people with capacity who refuse services and are at riskCarers – offer assessments, concerned curiosity & challenge, explore family dynamics, engage neighbours
Thematic Analysis – Team around the Adult
Recording – clarity & thoroughness of work done, agreed plans, outcomes achieved, discussions heldLegal literacy – know and consider available lawSafeguarding literacy – awareness of guidance & procedures, of risks and vulnerabilities, of safeguarding systems; adequate exploration of apparent choicesWorking together – silo working, threshold bouncing, shared assessments & plans, liaison & challenge, follow-throughInformation sharingAdvocacy – consider use with hard to engage peopleUse of procedures – DNAs, safeguarding alerts, risk assessmentsStandards of good practice – thoroughness of assessments, challenge professional optimism, lack of assertiveness & curiosity, authoritative practice
Thematic Analysis – Organisations around the Team
Support – cases are complex, high risk, stressful & demanding, so support systems essential; review scope and adequacy of policiesCulture – encourage challenge & escalation of concerns; balance personalisation with duty of care; review case management approachSupervision & managerial oversight – senior managers should take responsibility for overseeing complex cases; effective supervision; use risk panels; audit casesStaffing – practitioners must have appropriate experience & resilience; review allocation of work; mindful of health & safety
Thematic Analysis – LSAB around the Organisations
Conducting SCRs – involve family & carers, avoid delayMonitoring & action planning – robust action plans and audits of impact neededProcedures & guidance – develop protocols on risk & capacity assessments, follow up of service refusal, cases where adults have capacity but at risk of harmUse of SCR – across LSABs, in training, with government departments, for procedural developmentTraining – on mental capacity, law, procedures, writing IMRs, on person-centred approach & strategies to engage people; evidence outcomes
Themes from across Adult Safeguarding SCRs
Lack of compliance with statutory requirements; poorlegal literacyUncertainty about interface between different legal mandatesConcerns about practice standards, especially capacity assessmentsLack of training & unrealistic expectationsLack of management oversight of complex casesLimited interagency cooperationFocus on areas of agreementGroup thinkPower & status issuesRoles unclear, overlapping functionsDiffering levels of knowledge – of case, of specific issuesVariable definitions of professional ethics and need
Adult Safeguarding SCRs (2)
Poor sharing of informationIgnorance of case chronologyDivergent thresholdsPoor communication & recordingFailure to speak to the adult at risk & significant othersFailure to monitor communication & impact of contextAcceptance of poor standardsFailure to investigate; lack of rigour in inspectionFailure to follow through on decisionsFailure to escalateRule of optimism – staff and relatives are caringLack of curiosity and challenge
Corruption of care (Wardhaugh and Wilding 1993)Client characteristics leading to neutralisation of moral concernsPower and process in enclosed organisationsComplexity of work exacerbated by constraintsAbsence of accountability
Administrative evil (Adams and Balfour 1998)Conformity to organisational proceduresDulling of conscience and absence of independent critical thoughtErosion of personal judgementPublic policy-making encouraging moral inversion
Northway et al (2007)Commitment to multi-disciplinary workingIncreased clarity from proceduresGreater awareness of adult safeguardingOffset by policy overload, lack of joint working, time and workload pressures, limited knowledge of content of proceduresDiscretion which allows entry of personal values and actions
Preston-Shoot (2016)Repetitive findings in SCRs/SARsDo reviews give sufficient emphasis to the legal framework (how easy is it to understand and implement the legal rules across?) and to the mental models with which practitioners and managers approach this work?Do reviews adequately explore the connections between societal expectations, the national legal and policy framework, the organisational context, professional knowledge, norms and attitudes, and the service user/practitioner relationship?
Difficulty of obtaining SCRs limits learning.Emphasis on procedural development but guidance often ignored or not embedded.Emphasis on training but outcomes, if captured, variable.Does publication make a difference? Publication of executive summaries or full reports?No requirement to have local learning and service development strategies.Legal, ethical and organisational contexts important to explore in SCRs. Law seen as difficult to use; ethics difficult to navigateDescriptive but why do things map out the way they did?To what degree will the Care Act help with these cases – statutory LSABs, duty to cooperate, duty to review cases; but absence of power of entry & protection orders, and limited requirements to publish findings?
Adams, G. and Balfour, D. (1998)UnmaskingAdminstrativeEvil. London: Sage.Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Learning lessons about self-neglect? An analysis of serious case reviews’,Journal of Adult Protection, 17, 1, 3-18.Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Serious case review findings on the challenges of self-neglect: indicators for good practice’,Journal of Adult Protection,17, 2,75-87.Northway, R., Davies, R.,Mansell, I. and Jenkins, R. (2007) ‘Policies don’t protect people, it’s how they are implemented: policy and practice in protecting people with learning disabilities from abuse.’Social Policy and Administration, 41, 1, 86-104.Preston-Shoot, M. (2016) ‘Towardsexplanations for the findings of serious case reviews: understanding what happens in self-neglectwork.’Journal of Adult Protection(forthcoming).Wardhaugh, J. and Wilding, P. (1993) ‘Towards an explanation of the corruption of care’.Critical Social Policy, 37, 4-31.
Professor Michael Preston-Shoot
Executive DeanFaculty of Health and Social SciencesUniversity of BedfordshirePark SquareLutonLU1 [email protected]