Background
Adult O died as the result of a house fire in the morning of 22 February 2022. At the time of death Adult O, aged 81 years, was an adult at risk of harm under Adult Protection procedures. A number of individuals and agencies participated in their care and support due to concerns regarding self-neglect, fire risk, cognitive and physical deterioration.
Review process
An NHS Local Management Team Review (LMTR) found that a more proactive approach could have been taken and recommended improvements in multi-disciplinary consideration of cases involving increasing risk.
Given the range of agencies involved with Adult O’s care, it was agreed that a multi-agency Learning Review be initiated. Learning Reviews provide an opportunity for in-depth analysis and critical reflection to understand complex situations, enabling organisations to develop strategies to support and improve practice.
An external Lead Reviewer was appointed to bring further assurance to the family that someone independent was looking at the circumstances surrounding the fatality and a multi-agency Review Team supported the Lead Reviewer.
Adult O had been known to services since early 2021 and as such this Learning Review period runs from 18 January 2021 until their death on 22 February 2022. The family of Adult O has been involved throughout the Review.
Initial findings
The Learning Review contains a number of findings and recommendations for improvement.
Adult O had been independent, active, and proud but their family had seen deterioration in appearance, cognition, medication adherence and smoking behaviours. When raising concerns, the family did not feel ‘heard’ by services. Adult O was felt to have ‘hovered’ below risk thresholds and never quite ‘ticked the box’. The family stated that ‘nothing was joined up’ and wanted to help improve others’ experiences in future.
Areas of positive practice relate to the wide range of service involvement with Adult O:
- Sensory Impairment Team provided essential sensory equipment
- NHS employees made a referral to Scottish Fire and Rescue, and
- Home Fire Safety Visit was undertaken
Areas of improvement
A number of improvements were identified:
- earlier joint working on sharing and managing risk and decision-making
- recognition of family roles, expectations and carers assessment
- implementing strategies where self-neglect and non-engagement are involved
- clarity of referral processes in Home Fire Safety Visits and access to fire retardant equipment for the most vulnerable
- consistent awareness of the role of advocacy
- removing barriers to support, such as fee waiving for those most at risk, and
- revisiting case closure processes
An Improvement Action Plan is in place to embed the learning from this Review, and this will be monitored through Adult Protection Committee arrangements and the outcomes will be shared with multi-agency partners.