Gateshead Safeguarding Adults Annual Report 2023/24

The Safeguarding Adults Board devolves responsibility for the undertaking of undertaking of safeguarding adult reviews to the SARCC group. In 2023/24 10 safeguarding adult review referrals were received. 4 cases were discussed by the group using the rapid review process with 2 progressing to discretionary SARs. 6 of the cases did not meet the criteria to progress to rapid review.

Vice chair

In July 2023 the SARCC appointed a new vice chair following a change in representation at the group. Joanne Pendleton, Head of Adult Safeguarding, Gateshead Health NHS Foundation Trust took on the role.

Learning register

The group agreed to work on the development of a learning register to record the learning from SARs and provide a tool for the QLP group to monitor the actions and updates. Work continues to develop the register further to ensure assurance information from our partners is gathered and recorded.

Cross boundary working

One SAR referral involved an individual who had involvement with services from Stockton, Newcastle and Gateshead. The group demonstrated excellent multi-agency and cross-boundary working through the gathering or relevant information from across all LA areas, sharing this information and facilitating a meeting to ensure all partners were engaged and given the opportunity to consider how the case should progress. Safeguarding Adult Reviews

Parallel processes

The Gateshead Coroners office was provided with a copy of the learning review report for the Adult H case, the information provided was welcomed by the Coroner and assisted in establishing whether or not an inquest should take place. The SARCC Group is responsible, on behalf of the Safeguarding Adults Board, for statutory SARs introduced by the Care Act 2014. All reviews and enquiries are reported back to the SAR Group for scrutiny and challenge. Learning from reviews is fed into the Quality, Learning and Practice Group when there are specific actions or learning that needs to be taken forward.

Learning from SARs

There are key actions undertaken following the completion of a SAR In order to ensure the Safeguarding Adults Board takes forward the learning and recommendations:

• a multi-agency action plan is developed, this is agreed by the partners and regular updates are requested by the SG Business Unit. The action plans are monitored and reviewed by the QLP subgroup and any issues with the completion of actions are escalated via the Safeguarding Adults Board Executive
• single agency actions are monitored via the QLP Subgroup, a monitoring tool is used to ensure all actions are responded to by agencies and any issues are escalated via the Safeguarding Adults Board Executive and senior representatives of the agencies involved
• multi-agency briefings are designed and delivered to all partners, sharing the case information and the recommendations and actions with frontline practitioners
• resources and guides are developed and published on the Safeguarding Adults Board website which provides a useful resource library for practitioners

During 2023/24 the SARCC received 10 Safeguarding Adult Referrals, none progressed to mandatory SAR:

Referral 1 (Adult H)

Adult H passed away on 1st April 2023 at the age of 64 years, there was very little information known about him.

On 29 March 2023, a Management Officer from Karbon Homes attended Adult H's home address on a arrears visit as rent had not been paid for one month. It is reported that Adult H crawled to the front door to answer due to a 'fall' he had some weeks early, he could not remember the exact date. Adult H was short of breath and struggling to manoeuvre about. He was also very slim and did not have any food in his cupboards or heating on. The Management Officer called an ambulance.

Adult H told the ambulance crew that he had not eaten for a month due to sanctions on his benefits. He lived alone, there was no food or drink in the property, he had been sleeping on his sofa and going to the toilet there. Northeast Ambulance Service records provided this description "the patient and the home were described as unkempt, only one working light in the property no bulbs in other rooms and the heating system was turned off".

Adult H was transferred to the Queen Elizabeth Hospital in Gateshead on 29 March 2023, where he passed away two days later.

SARCC Recommendation - The case did not meet the criteria to progress to a mandatory SAR however the group felt that there was learning which could be taken from the case. See Learning from SARs for further information.

Referrals 2 and 3

Both of these referrals were in relation to ladies who were experiencing multiple complexity in the context of their alcohol use. There was sufficient evidence from local and regional SAR data and from the Second National SAR Analysis (LGA 2023) as well as local and national health data to suggest that there was a need to provide alternative approaches and care pathways for change resistant drinkers. In response to this the Local Authority have agreed to fund the implementation of the Blue Light Project which provides a model for assertive outreach and focuses on harm reduction and risk management.

SARCC Recommendation - The members of the SARCC group recommended that the cases be referenced in a thematic of cases where alcohol misuse and mental health issues were evidenced, but where the people did not have care and support needs. Work on a thematic review is being undertaken jointing with Public Health.

Referral 4

This lady passed away on 2 November 2023 aged 30 years. She had a history of alcohol dependence and was also the victim of domestic abuse, she had mental health problems but did not appear to engage with services. The death of her mother in 2017 played a significant part in the decline in her mental health. She was often reported to be unkempt, and the condition of her home was at times concerning.

Originally from Stockton-on-Tees she had moved to Gateshead in June 2022, she had a diagnosis of Emotionally Unstable Personality Disorder and Complex Post Traumatic Stress Disorder. She was supported by mental health services (TEWV and CNTW), social care services, and treatment and recovery services. She was supported with accommodations through Gateshead Housing and was a frequent attender at A & E departments in North Tees, Gateshead and Newcastle.

She had engaged with Gateshead Recovery Partnership (GRP) and received support including dayhab, behaviour change and psychosocial interventions but had frequent relapses and continued to struggle with her alcohol use. Quality Assurance - Learning from SARs and other Enquiries The SARCC group reviewed this case in January 2024, and were joined by representatives from Stockton and Newcastle Safeguarding Adults Board areas to consider how partners had worked together to provide support and, it was clear from the information provided that all partners had demonstrated good cross boundary working in light of the difficulties in engaging with this young lady.

SARCC Recommendation - The members of the SARCC group and representatives from Stockton and Newcastle agreed that the case did not meet the criteria to progress to a SAR, however the case would be considered alongside referrals 2 and 3 for inclusion in a thematic review. This action has now been superseded by the LA's funding for the implementation of the Blue Light project.

Referral 5

This case related to a gentleman who resided in a care home in Gateshead. At the time of death, the gentleman was the subject of a Section 42 enquiry relating to injuries he had sustained following an unwitnessed fall.

SARCC Recommendation - The case did not meet the criteria to progress to a SAR and the SARCC asked that a single agency review should be undertaken by the care home in response to the issues raised in the SAR referral.

Referral 6

A SAR referral was received in relation to a lady who died on 24h December 2023. Adult Social Care and Gateshead Housing had worked closely to support this lady and had regular contact with her, raising their concerns with her regarding abuse and neglect by a third party. There was evidence of that the lady used alcohol and issues were raised regarding self-neglect, mental capacity and services being unable to connect with the individual. The lady had been contacted by domestic abuse services but it would appear that she refused to engage with them.

SARCC Recommendation - The cause of death at time of writing is still unknown, the SARCC have agreed to postpone a decision to process until this is available, consideration is also being given to a joint DHR/ SAR, this is pending a response to the police regarding their ongoing investigation into the case.

Referral 7

This case related to a lady who resided in a care home in Gateshead. At the time of death, the lady was the subject of a Section 42 enquiry relating to injuries he had sustained following an unwitnessed fall.

SARCC Recommendation - The case did not meet the criteria to progress to a SAR and the SARCC asked that a single agency review should be undertaken by the care home in response to the issues raised in the SAR referral.

Referral 8 (Adult J)

A Safeguarding Adult Review referral for Adult J was received from the Queen Elizabeth Hospital Safeguarding Team on 31 January 2024 following her death on 27 January 2024. Adult J lived with her daughter and grandson who provided care and support for her. She was of Polish decent and moved to the UK in 2021 following the death of her husband. She spoke no English and relied on her family to interpret for her. The referral raised concerns regarding the care that Adult J had received whilst living at home with her daughter and her grandson and the resulting pressure damage. Questions were raised regarding the family's ability to care for Adult J given her very limited mobility.

SARCC Recommendation - The case was discussed at the SARCC group meeting on 12 March 2024. Information was provided from agencies from both Gateshead and Durham, this helped the group to obtain a fuller picture of Adult J's case, who was providing care and where there were gaps in service or concerns regarding the care provided. It was agreed that although the case did not meet the criteria for a mandatory SAR that there was learning to be considered and that a discretionary SAR should be undertaken. The Assistant Director of Nursing, NENC ICB agreed to chair the practitioner session which is arranged to take place in June 2024.

Referral 9

A referral was received for this gentleman following his death on 12 March 2024. Although there was evidence that he had the appearance of care and support need no care act assessment had been undertaken. Services appeared to have worked together to try and safeguarding him, however agencies were often unable to make contact with him and if they were able to contact him and offer support he declined.

Referral 10

This SAR referral related to a lady who had suffered a double above knee amputation, following a stroke. The SARCC group were considering the case at their meeting in June, following the gathering of further information at which point it was ascertained that there had been a delay in referrals for the lady from their GP to the Vascular Team at the RVI. There was however no evidence that this delay would have changed the outcome for the lady.

SARCC Recommendations: SARCC agreed that the case did not meet criteria to progress to a SAR, however it agreed to ask for assurance from the GP practice concerned that they have robust processes in place to ensure referrals are made in a timely manner.