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Serious Case Review of Jersey pensioner published

20 April 2018

​A Serious Case Review into the circumstances surrounding the final weeks of an 89-year-old man’s life has been published by the Independent Chair of Jersey Safeguarding Adults Partnership Board.

The SCR, issued today by Glenys Johnston OBE, is conducted in a way which respects the person’s privacy so the 89-year-old has not been named in the review and instead is referred to as ‘Mr Hunter’.
The review concluded that although Mr Hunter lived in ‘squalid’ living conditions regarding hygiene, safety and sanitation, for 40 years, there was no evidence that his death was directly associated with his living conditions.

Details in the review include:

• Mr Hunter lived in “off-grid” accommodation, initially in wooden containers from which he gained some income by renting out to others.
• His living conditions included no electricity, no toilet, presence of rats, no running water and having no cooking facilities.
• Agencies worked together to try and reduce risks to him as well as to the public. This response included condemning his caravan under Environmental Health regulations, against Mr Hunter’s wishes.
• Mr Hunter’s living conditions were described by some agencies as ‘squalid’. They were concerned he was putting his own health and safety, and the health and safety of others, at risk. Mr Hunter disputed this and was very happy with his lifestyle – neither he or his next of kin accepted that he was neglecting himself.
• Mr Hunter was well known to the parish, which had tried over the years to support him.
• In 2017, a referral was made to Jersey Adult Social Care – a single point of referral under the multi-agency self-neglect guidance.
• The review went on to say that there was no evidence that Mr Hunter had any mental impairment which was affecting his ability to make decisions.
• Mr Hunter developed an infection and decided against having the surgery that was needed to save his life.

Difficult decisions

The review went on to say that last months of Mr Hunter’s life were very difficult for him. His next of kin’s view was that the intervention by agencies to prevent him living in the way he wished was disproportionate to risk and that the intervention adversely effected his wellbeing.
The review highlighted the difficulty of respecting an individual’s right to a private life at the same time as trying to keep them safe from harm, in this case self-neglect.
Although there was clear evidence of good practice from certain agencies there was a recommendation that more training and awareness is needed around the issue of self-neglect.
It has also highlighted the challenging practice and ethical dilemmas of working with people defined as self-neglecting and how those agencies tried to navigate through this.
Many examples of good practice were displayed in the review by agencies working together and the care and compassion shown by front-line officers who tried to help Mr Hunter from the States Police, Parish, Fire Service and Ambulance.

Safeguarding Partnership Board:

Chair Glenys Johnston said: “The Safeguarding Partnership Board has already taken positive steps to address self-neglect in Jersey. The review has identified areas that may further strengthen multi-agency work in responding to self-neglect. The review also highlighted areas that will strengthen multi-agency work in responding to self-neglect and the valuable contribution that the parishes can play in safeguarding. The purpose of an SCR is not to apportion blame but to ensure that lessons are learned and improve the way adults are safeguarded.”
All the agencies who had contact with Mr Hunter were involved in the review and have considered the recommendations made as part of this SCR.

Jersey Safeguarding Adults Partnership Board (SAPB) will arrange for a Serious Case Review (SCR) when an adult (with needs for care and support) dies from, or has experienced serious abuse or neglect and there is concern about how the SAPB, members of it or other persons with relevant functions worked together to safeguard the adult.

The purpose of SCRs is to promote learning and improvement between agencies to safeguard people more effectively. SCRs are not concerned with attributing blame and are not part of any disciplinary matters.

A SCR enables all of the information known to agencies to be seen in one place. This is beneficial to learning though recognises that this hindsight knowledge was not all available to individual practitioners at the time.
An independent author was asked to carry out this review. The author, Sylvia Manson, is an experienced author of reviews, holds a professional background in Social Work, mental health services and safeguarding adults and is independent of the SAPB and its partner agencies.

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