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Publication of Serious Case Review

12 May 2016

​The Safeguarding Adults Partnership Board has published a Serious Case Review (SCR) in respect of a man in his nineties.

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

The circumstances outlined in the report are that Mr Benjamin (not his real name) died as a result of multiple and complex health problems and there were concerns about poor co-ordination of support and care for him and his wife at home and at a residential home. His death was not hastened by the actions of agencies but his care towards the end of his life could have been better co-ordinated.

Lessons are learned

Mrs Johnston said "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 Benjamin and his family differently. The purpose of an SCR is not to apportion blame but to ensure that lessons are learned and to improve the way adults are safeguarded.”

All the agencies that had contact with Mr Benjamin were involved in the review and have considered the recommendations made as part of this SCR. The report found that:

  • There was insufficient co-ordination of care. Agencies didn’t respond quickly enough to Mr Benjamin’s deteriorating situation at home and their efforts were not well co-ordinated. There was a similar theme both in terms of hospital discharge planning in early 2015 and overall co-ordination of support to Mr Benjamin when his health deteriorated rapidly in the residential home.
  • There was inadequate assessment of Mr Benjamin’s capacity for decision making. And not enough thought was given to what would happen if his health became significantly worse and whether Mr Benjamin was able to contribute to that discussion and any subsequent decisions.
  • Mr Benjamin and carers weren’t adequately listened to. The family felt let down by agencies that seemed to respond slowly to the deteriorating health of Mr Benjamin.

Link to Mr Benjamin Serious Case Review (848KB)

As a result of the report, the recommendations include:

  • When an individual is to be discharged from hospital to a care home or nursing home, the hospital must provide comprehensive medical information and homes must be empowered to get that information from hospitals and GPs if it is not readily available.
  • Jersey Hospital, and Community and Social Services formalise, in joint procedures, their responsibilities for effective hospital discharge and if there are any concerns from either organisation, these are highlighted and resolved.
  • The Safeguarding Partnership Board cannot be completely assured that joint working to support vulnerable and frail individuals is co-ordinated and effective, so it will introduce a programme of multi-agency case file audits that provide assurance that the problems encountered in this case and a previous learning review are not encountered routinely.
  • The Safeguarding Partnership Board introduces draft codes of practice in relation to capacity, in advance of anticipated legislation and supports their introduction with a programme of training events.
  • Professionals involved in completing assessments should ensure they listen to families and carers, include them in the assessments and plans and provide them with copies of these. This should be included in regular audits of practice.
  • Assessments should ensure that the appropriate placement (nursing or residential care) meets the needs of the service user and is regularly monitored and changed if appropriate. Professionals who are concerned that the placement is inappropriate, should raise their concerns and if necessary use appropriate escalation procedures.

Link to Mr Benjamin Serious Case Review learning report (313KB)

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