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Serious case review published

15 July 2015

​​The Safeguarding Adults Partnership Board has published a Serious Case Review (SCR) into the death of a man in his early 60s.

The SCR has been published by the Independent Chair of the Safeguarding Adults Partnership Board, Glenys Johnston OBE.

The circumstances outlined in the report are that Mr Arthur (not his real name) was  found dead at his home on 11 January 2014 and, according to the results of an inquest held in June last year, had died six to seven months before his body was discovered. He had last been seen alive on 20 June 2013. There is no evidence that anyone else was involved in his death.

Mr Arthur had a long history of alcoholism and was known to have illnesses related to his drinking. He neglected himself and his living conditions were known to be poor and unsanitary, especially in the last two years of his life. He had refused support on a number of occasions, over many years and had made it clear that he did not want to address his dependence on alcohol, despite the loss of a successful career and the support of his former wife and children.

Impact of alcoholism

He was vulnerable through misuse of alcohol, his care of himself deteriorated over time and in his last years he became increasingly isolated.

Mrs Johnston said “The alcoholism had a devastating impact on Mr Arthur’s life. Given the high rates of alcoholism in Jersey, it is essential that public note the risks associated with drinking and that agencies take on board the learning from this review and implement the recommendations so that similar suffering and loss of life can be avoided.”

The circumstances leading up to his death meet the criteria for conducting a SCR, the purpose of which is to determine whether there were opportunities to support Mr Arthur and aspects of his self-neglect which had been missed and what could have been done differently. The purpose of an SCR is not to apportion blame but to ensure that lessons are learned and improve the way adults are safeguarded.

Report findings

The author of the report found that:

  • several agencies had contact with Mr Arthur over a long period of time and although concerns were raised, the agencies did not come together to discuss them or plan future support.
  • assessment was not made of his capacity to choose to live in the way that he did. These assessments should have been carried out periodically.
  • with the benefit of hindsight, there had been opportunities to engage Mr- about the management of his decision to continue drinking.
  • Mr Arthur’s early death was predictable on statistical grounds, due to his long term and heavy consumption of alcohol, but it is impossible to know whether it was preventable as the cause of his death is unknown.
  • intervention may have helped him manage his drinking in a safer environment.

Report recommendations

As a result of the report, the recommendations are that:

  • people who take high risk decisions, including self-neglect, should be assessed for their capacity to make decisions.
  • people who do not engage with services should be contacted regularly to check that their choices and their capacity to make those choices, has not changed.
  • referrals to Adult Social Services should be thoroughly assessed and reasons should be given to the referrer if the decision is not to offer a service.
  • the decision to close cases should follow a risk assessment.
  • consideration should be given to creating a support service for people at risk through alcohol use but who do not need accommodation.
  • increased training for professionals in identifying, treating and supporting people with mental health disorders related to alcohol use.

"All the agencies who had contact with Mr Arthur were involved in the review and will consider the recommendations made as part of this SCR. However, it is also important that we all look out for the vulnerable members of our community and seek assistance or advice when we think neighbours, family or friends may need help. Safeguarding is everybody’s business," said Mrs Johnston.​

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