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Missed opportunities to provide support to elderly Derbyshire man dying due to “severe self-neglect”

The Derbyshire Safeguarding Adults Board considered the case of a man referred to as William, in his 80s, who had depression, schizophrenia and extensive mobility issues and was visually impaired.

A safeguarding adults review carried out into William’s death showed that the wide range of health professionals who were consistently in touch with him did not work close enough together or in a joined-up manner with one agency taking the lead.

“At no time did all agencies involved meet to assess risks, plan responses, appoint a lead and agree contingency planning and review,” the review said.

The criteria for a vulnerable adult risk assessment (VARM) was met on eight occasions but “no agency took forward ownership to initiate the VARM process until William’s final admission to hospital which sadly, was the day he died”, the review stated.

Five referrals for safeguarding adult enquiries were made but these were never progressed.

A review report on William’s case said: “William’s lack of care for himself resulted in loss of weight, pressure sores, lack of personal hygiene and continence care and unkempt clothing.

“He was a keen smoker and often had burns to his face from lighting cigarettes from an open gas flame. 

“The conditions of his environment were described as uninhabitable due to lack of heating, minimal lighting, levels of clutter, unhygienic conditions including slippery floors due to lack of continence. 

“This placed him at risk of hyperthermia, increasing falls and fire risk.”

The report said William had been active before the pandemic, regularly visiting a local cafe, but this ended when restrictions were brought in and his reduced mobility during this time ended up leaving him housebound.

He was well supported by his neighbours and had some phone contact with his sister and a friend but he often spoke of “loneliness and isolation” in the three years after, up until his death.

The report continued: “William had a high level of involvement from health agencies, adult social care and fire and rescue services. 

“William was well engaged with health services and could be amenable to receiving help for his physical and mental health needs, at times, being proactive in requesting help. 

“However, he could struggle to take medications consistently and declined some aspects of care such as aids/adaptations and some hospital admissions.

“William minimised the concerns. He repeatedly declined care and support, either because he did not want to pay and/or did not feel he needed it. 

“On occasions when he had agreed to accept some support, this consent was soon retracted. William was resolute that he wished to remain in his property despite its condition.”

The review found that while many professionals were involved in William’s care, they were rarely the same people, leading to issues gaining his trust and ability to comprehensively understand his situation in full.

There was a “lack of consistent health and care practitioners” and a “lack of adequate multi-agency responses”, it said.

It detailed: “Overall, there was an episodic and fragmented response to the concerns raised regarding William. Practitioners did not all recognise the recurring nature of the concerns, William’s disguised engagement and the escalating risks. This led to repeated cycles of arranging care plans that had already proved to be unsuccessful.”

Simon Stevens, the council’s executive director of adult social care and health, said: “I’d like to express my heartfelt condolences to everyone who knew and loved William.

“We accept the findings of the review and we continue to ensure that all the learning points raised are fully implemented.

“This includes updating our named worker guidance to ensure people at risk as a result of severe self-neglect receive consistent support. 

“We are working closely with the Derbyshire Safeguarding Adults Board and our partner agencies around the lack of effective joined up working identified in William’s case and a series of actions have been agreed and implemented.

“Cases like these are extremely distressing which is why we have also worked alongside the Board to develop a toolkit to help support professionals so we will be better placed to ensure that a similar event is prevented in future.”


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