The most important purpose of serious case or inquires is not for anyone to be blamed for any relevant incident leading to investigation. It is a lesson learnt from the incident where health professionals collaborate to s safeguarding vulnerable adults. In most cases this helps to improve practice and for health professionals to be aware of how procedures can be effective.
Case reviews are usually utilized to improve practice and also improve you to work with other health professionals. Any case reviews with health professionals which are in progress they are able to make recommendations for the organisations to improve future occurrence of incident and to review safeguarding procedures. Adult abuse is very prevalent and occurs in various forms. It can consist of single or repeated act. i.e. physically, verbal, psychological, neglect, financial and sexual with consent. I had an experience with a resident who had type 2 diabetes and was mobile with aid of a walking stick he had mental capacity and was able to make decision for himself.
He had develop a pressure ulcer to his left little to where it became neurotic at times he will let the nurse clean and dressed it and other times he will declined we then request referral for tissue viability he was seen and was diagnosed grade 3 pressure ulcer we then had to report this to safeguarding and CQC. The one thing I have learnt from this incident is it was considered ad neglecting a vulnerable adult which was not our fault as he had capacity and declined some intervention. If there is an allegation concerning a member of your staff, your procedures are likely to require you to suspend the person pending the outcome of the investigation or, at least, find them duties that do not bring them into contact with vulnerable adults.
Once the safeguarding or police investigation has concluded, and if the allegation is upheld, you will then have to follow your organization’s disciplinary procedures to decide what happens to the member of staff. If someone working in social care is arrested and charged with a criminal offense, the police will notify the Disclosure and Barring Service (DBS) and the local safeguarding team, as social care is a ‘notifiable profession’. If there are no criminal charges, but a safeguarding investigation concludes that an allegation is upheld, then the responsibility rests with you to notify the DBS. Having a member of staff who abuses vulnerable people is always difficult to deal with and will inevitably make you question how it happened and reflect on what you could have done to prevent it. Everyone in the team is affected by that sort of event and a ‘review and reflect’ session with staff can help to re-settle a troubled team. The Social Care Manager, The National Skills Academy Serious Case Review concerning the death of Edward Hedley 10 March 2016 The Newcastle Safeguarding Adults Board has published the report of a Serious Case Review concerning the death of 91-year-old Newcastle man Edward Hedley.
This follows the prosecution of Mr. Hedley’s son William Hedley who was found guilty of willful neglect of an adult lacking in mental capacity at Newcastle Crown Court on 2 February 2016 and sentenced to 18 months imprisonment. The verdict was particularly welcomed, as there are few examples of a relative or family member being prosecuted under Section 44 of the Mental Capacity Act 2005. A number of agencies who contributed to the Serious Case Review were pivotal in bringing the case to trial. Mr. Hedley died on 12 January 2013.
The Serious Case Review was undertaken because “an adult had died and abuse or neglect was known or suspected to be a factor in his death”. The report finds that Mr. Hedley was a very independent man who preferred to find his own solutions to any difficulties he encountered. This was evident from his first contact with the hospital service in 2005, where he declined medical advice, ongoing medication, and care. The report finds that the intervention of Mr. Hedley’s son made it very difficult for the authorities to provide appropriate support to Mr. Hedley.
William Hedley did everything in his power to prevent access to treatment and went to considerable trouble and expense to achieve his purpose. The independent author of the report Tom Wood concludes: “it is hard to envisage that public services will soon again encounter such trenchant resistance to such obviously necessary care for a vulnerable adult. It is difficult to make meaningful recommendations from such an extreme case since it is unlikely that such circumstances would recur in the near future. However, it is important that any death in such tragic circumstances is fully considered so that lessons can be learned”. Responding to the report the independent chair of the Newcastle Safeguarding Adults Board, Vida Morris said: “This is a tragic case and a matter of huge regret to all the agencies that made determined efforts to try to help Mr. Hedley.
Whilst it is difficult to see what could have been done in the face of such deliberate obstruction, it is very important that we have explored the actions that were taken to ensure that lessons are learned. Given the rarity of such prosecution, it is hoped that learning can be shared nationally as well as locally. All the recommendations in the report are accepted and resulting actions have either been fully implemented or are nearing completion.” Newcastle Safeguarding Adults Board, www.newcastle.gov.uk Professional Learning In the Serious Case Reviews that I have mentioned, the following may be considered safeguarding concerns:
- Denying adults at risk access to professional support and services such as hospital treatment.
- Denial of individuality and opportunities for service users to make informed choices and take the responsible risk.
- Service users’ dignity is undermined due to a lack of mental capacity.
- Failure to support an adult at risk to access health and or care treatments