Southampton Safeguarding Adult Board - Thematic Safeguarding Adult Review - Ahir and Peter

Introduction

1. The Care Act 2014 states that Safeguarding Adult Boards (SABs) have a statutory responsibility to arrange a Safeguarding Adult Review (SAR) when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked together more effectively to protect the adult. Under Section 44 (4) of the Care Act 2014, SABs are free to arrange a discretionary SAR where it believes there is value to do so.
2. Southampton SAB Case Review Group (CRG) received two separate referrals for two men, Ahir and Peter. The two men both lived in Southampton, but did not know each other. Although not statutorily being provided with care and support as defined under the Care Act 2014, it was recognised that both men required care and support, that their deaths had occurred from abuse or neglect (including self-neglect) and there was reasonable cause for concern about how agencies worked together. CRG determined that there were a number of similarities in the lives and experiences of both men, and that there was clear learning to be identified. A discretionary Thematic Safeguarding Adult Review was commissioned by SSAB.
3. The overall purpose of this Thematic Safeguarding Adult Review is not to re-investigate or apportion blame, but to promote learning and improve practice and services for those who use them, their families and anyone in a caring responsibility for a vulnerable adult.

Reason for the Safeguarding Adult Review

1. Ahir¹ was 54 years old when he was sadly found deceased by his landlord at his home address. Police officers observed poor living conditions in his property and that Ahir did not appear to have changed his clothes for some time. There were empty bottles of vodka and mould throughout the flat.
2. Peter was 64 years old when he was sadly found deceased. Concerns were raised for Peter after it was established he had not collected his medication for over 12 months. Police officers attended and found the front door shut but unlocked. On entry, letters had to be pushed back to open the door and a heater was found running. Peter’s address was sparse, with a makeshift bed in the living room. The living room was in a poor condition with rubbish bags around the room. The kitchen was empty and had no oven, fridge, freezer or microwave and no evidence of any food present. Based on the last agency contact and post at the address, it is believed that Peter had passed away 16 months prior to being found.
3. During the time period examined, both Ahir and Peter presented with ongoing physical health and mental health needs. Both expressed they hoped they would die and that they struggled to leave their homes.
4. Ahir and Peter each came into contact with a number of agencies throughout the review time period. There appeared to be times when Ahir and Peter disengaged from support services and the offer of further support was reliant on their level of engagement.
5. It was not always clear whether the Mental Capacity Act (MCA) was considered because there was no reason to doubt Ahir’s and Peter’s capacity. In Ahir’s case, when the MCA was considered, this was at a late stage.
6. There was some evidence in agency records that Ahir’s and Peter’s voices and wishes were captured, but there was a gap in agencies trying to understand the underlying reasons for their self-neglect, mental health concerns, substance use and fluctuating engagement.

(1) Pseudonyms have been used for this review.

Scope of the review

1. The review timeframe was June 2021 to July 2023.
2. Key lines of enquiry:
   • How did professionals engage with Ahir and Peter?
   • Were the risks of harm to Ahir and Peter fully recognised by professionals and appropriate action taken to manage these?
   • Was the individual’s voice heard by professionals and their views and wishes taken in to account?
   • How was the Mental Capacity Act applied?
   • How does stigmatisation attached to individuals who use substances and/or self-neglect have an impact on their access to services?
   • How effective is multi-agency communication and working when individuals are perceived as not engaging?
   • Was there effective challenge and escalation when support services were closed?
   • How can agencies engage with individuals where high risk self-neglect is evident?
3. Agencies involved:
   
   • Change Grow Live (CGL)
   • Hampshire and Isle of Wight Constabulary
   • Hampshire and Isle of Wight Fire and Rescue Service (HIWFRS)
   • Primary Care/Integrated Care Board (ICB)
   • Solent NHS Trust
   • Southampton City Council Adult Social Care (ASC)
   • Southampton City Council Housing
   • Southern Health Foundation Trust (SHFT)
   • South Coast Ambulance Service (SCAS)
   • University Hospitals Southampton Foundation Trust (UHS)
4. Methodology:
   To support the review process, representatives from the agencies involved in the review time period were asked to provide relevant single agency information and the local context within which the safeguarding system works. A practitioner workshop was also held to examine Ahir’s and Peter’s stories in more detail and bring their experiences with local agencies to life.

Family engagement

1. As part of the review process, Ahir’s family and Peter’s niece were contacted. Ahir’s family and Peter’s niece met with the author and provided valuable insight into their loved one’s lives.

Parallel investigations

1. Peter’s death was subject to a Coroner’s Inquest which was held on the 23rd October 2024 and concluded that Peter’s cause of death could be unascertained due to the severe state of decomposition. Ahir’s death was not subject to a Coroner’s Inquest as it was determined that he passed away from natural causes, specifically alcohol related liver disease.

Ahir’s story

1. Ahir was a 54 year old man of Asian heritage who lived alone in private housing. Ahir was born in Southampton and had three adult children. Ahir was unemployed at the time of his passing but had previously been a finance role. Ahir’s family described Ahir as an intelligent man who was “the life and soul of the party” who would “do anything for anyone”.
2. Ahir had poor eyesight, was partially deaf and experienced poor mobility. He had depression and was alcohol dependant. He also disclosed infrequent cannabis use. The family informed the author that Ahir had a diagnosis of Bipolar Disorder and believed he may have been neurodivergent.
3. On 6th July 2021, Ahir attended the Emergency Department due to excessive alcohol consumption. Ahir was seen to be having a suspected seizure and an ambulance was called. Ahir was assessed by the Vulnerable Adult Safeguarding Team (VAST) in hospital who deemed he was safe to return home. Later that day, Ahir contacted police to report his neighbour had his key, but would not return it. Police did not attend Ahir’s address until four days later where they found Ahir’s property to be insecure and there was no sign of Ahir. Officers did not consider there to be a safeguarding concern or a possible crime that had taken place. Whilst a PPN² was completed two days after the visit to the property and shared with Adult Social Care (ASC), this had little information on it for sharing with agencies and referenced possible mental health difficulties but without any context of Ahir’s mental health. ASC recorded receipt of the PPN for information purposes.
4. On 7th July 2021, Ahir had contacted Change Grow Live (CGL) by text message to state he had been really poorly for five weeks and had lost a lot of weight. Ahir didn’t respond to a returned text message, but it doesn’t appear any consideration was given to completing a safeguarding referral, completing a home visit or offering further support to Ahir such as food bank vouchers.
5. In late July 2021, Ahir spoke to CGL on the phone and reported he was eating well, feeling better, not consuming alcohol and was seeing his GP for his physical and mental health. A decision was made to move Ahir in to Recovery Support as he reported he was not drinking alcohol, but no face to face appointment was given to corroborate the information Ahir had given about feeling better.
6. On 28th September 2021, the South Coast Ambulance Service (SCAS) raised a safeguarding referral with ASC due to concerns Ahir was not looking after himself and was consuming alcohol. ASC made multiple calls to Ahir over a two day period, but no response was gained. On 29th September 2021, ASC attempted to contact Ahir’s brother, sister and father. There was no answer from any family members, so voicemail messages were left. ASC also contacted the local hospital to see if Ahir had been admitted. As there had been no response from Ahir or his family, the referral to ASC was closed.
7. On 19th October 2021, Ahir’s mother contacted ASC as Ahir was not eating, not washing, drinking heavily, experiencing mental health difficulties and not leaving his home. Ahir’s mother had tried to contact Ahir’s GP, but without success. It is recorded that Ahir’s mother spoke little English, but advised ASC she wanted to be contacted and get support for Ahir. ASC spoke with Ahir’s brother the following day who advised the family had been trying to get Ahir help, but he doesn’t always engage with the support offered. ASC signposted the family to CGL, Ahir’s GP, the mental health team and NHS 111.
8. On 15th November 2021, Ahir attended a dietetics appointment and reported he weighed less than 48kg (7.5 stone) and was vomiting when he ate. Ahir reported he was under a lot of support services, but this was not confirmed. Ahir reported he was not ready to make changes and was discharged.
9. On 13th December 2021, Ahir told CGL that he was feeling well and had not drank alcohol for 25 days. He reported going to church and was taking his prescribed medication. He wanted to explore getting back in to employment.
10. On 5th January 2022, Ahir contacted police as he reported 5-10 people trying to break in to his address. Officers arrived three minutes after the call was made, but could not locate anyone and there was no evidence of a break in. Ahir reported he hadn’t slept for seventy-two hours and may be hallucinating. Officers completed a PPN recording that they believed Ahir was experiencing mental health difficulties, but the PPN was not shared with Ahir’s GP as Ahir told officers he had already told his GP. On the same day, Ahir had telephone contact with his GP where he reported “seeing ghosts for years”. The GP referred Ahir to Early Intervention Psychiatry and prescribed Ahir quetiapine. Later that day, Ahir called the police again to report there were gangs outside his address “making balls of fire” and he can see “women being harmed”. Ahir was asked to contact the fire service (HIWFRS), but it does not appear that he did. As police officers were not deployed, no PPN was completed.
11. On 13th January 2022, the Early Intervention Psychiatry team advised Ahir did not meet the criteria for their service and recommended he continued to engage with CGL and a referral be made to the Community Mental Health Team (CMHT). Ahir maintained regular contact with his GP around this time.
12. In February 2022, Ahir attended some CGL groups and appointments were made for Ahir with employment support. Ahir stated he wanted to find employment that was meaningful and provided him with a routine. He attended a face-to-face GP appointment and was described as well dressed and kempt. Ahir disclosed a long history of alcohol use to his GP and past trauma from physical and sexual abuse. It was not clear if he had accessed any support for this. He disclosed using cannabis once a year.
13. In March 2022, Ahir failed to attend planned appointments with employment support. On some occasions he communicated this to CGL via text message stating he had not been doing so well in recent weeks. The reason for him feeling this was not explored. Ahir’s attendance at CGL groups and appointments improved in April 2022 and he had sorted his benefit payments. On 12th April 2022, Ahir missed a GP appointment for a review of his medication. The GP notes Ahir’s compliance with his prescribed medication was not consistent. There is reference to Ahir having an assessment with CMHT on 9th February 2022, where he was deemed not suitable and transferred back to his GP. He was also signposted to debt management support by CMHT.
14. On 23rd May 2022 Ahir sent a text to CGL stating he “hadn’t left his flat in months”, despite attending some, but not all scheduled in person meetings with CGL and employment support. He informed CGL that he had not been eating or sleeping well and was worried about his daughter, but there was no follow up with Ahir as to the specific nature of what was concerning him or contact made with his GP. Ahir was last seen by CGL on 6th June 2022. Numerous phone calls, voicemails and text messages are made throughout June by CGL, but with no response from Ahir. Ahir was closed to employment support in early September 2022. Correspondingly Ahir’s GP was also unable to get hold of him during this time period.
15. On 9th September 2022, Ahir was found by his landlord crawling on the pavement and behaving in an unusual manner. Ahir was described as agitated and experiencing a seizure related to alcohol withdrawal. Two days later, an MCA assessment was completed and Ahir was found to lack capacity. He was placed on Deprivation of Liberty Safeguards (DoLS)³. On 20th September 2022, Ahir was discharged from hospital back to the care of his GP. A new referral was made to CGL by the hospital on 21st September 2022 for Ahir to enter structured treatment. CGL called Ahir on 7th October 2022, but got no response. There was no further attempt by CGL to contact Ahir again until 8th December 2022. After several unsuccessful contact attempts, the referral to CGL was closed on 12th December 2022. Ahir’s GP made numerous attempts to contact Ahir following his hospital discharge, but these were also unsuccessful.
16. On 3rd February 2023, Ahir’s sister-in-law contacted Ahir’s GP as she was struggling to look after him on her own. The GP was sent photographs of Ahir’s flat which was seen to be in a poor condition. Ahir’s sister-in-law reported Ahir told her he wants “to be left alone to die”. The GP completed a referral to CMHT and CMHT offered Ahir an assessment for 22nd February 2023. Although the outcome of this assessment is not recorded, it appears from agency records in March 2023 that Ahir did not meet the criteria for CMHT support and he was referred back to his GP.
17. On 16th February 2023, SCAS made a safeguarding referral to HIWFRS due to concerns Ahir was self-neglecting, that he was being careless with smoking materials and there were concerns he would be unable to adequately respond to a fire. HIWFRS visited Ahir at home on 27th February 2023 (with Ahir’s sister-in-law present) and issued him with fire retardant bedding. Ahir stated he wanted support with his alcohol use. HIWFRS raised a safeguarding concern to ASC as Ahir’s property was in a poor condition, with food and rubbish on the floor. Ahir reported missing his medication, not eating properly and not using the heating.
18. On 23rd March 2023, CMHT record a referral received from ASC for Ahir, but confirmed with ASC that he had been discharged back to the care of his GP. An urgent referral was made by CMHT to CGL for Ahir. On 3rd April 2023, ASC contacted Ahir’s GP enquiring if he was receiving support for his mental health after CMHT requested ASC complete an urgent Section 9 assessment⁴ for Ahir. Attempts were made by ASC to contact Ahir, but these were unsuccessful. In the following two weeks, ASC, CGL and HIWFRS attempted to contact Ahir, but gained no response.
19. On 14th April 2023, HIWFRS provided ASC with Ahir’s sister-in-law’s details in an attempt to contact Ahir. ASC contacted Ahir’s sister-in-law on 17th April 2023 who stated he was drinking heavily and subsequently unable to accept support. His flat was in a poor condition, he was hallucinating, he was not taking his medication and he was carrying a knife for self-defence. Ahir’s sister-in-law told ASC she felt as though she was waiting for a call to inform her that Ahir was dead. ASC advised Ahir’s sister-in-law they would not be conducting a visit as there was no evidence of need for longer term ASC input, the concerns were shared with Ahir’s GP to refer to mental health services and an urgent visit to Ahir by the GP was requested. Ahir’s case was transferred to the Locality Community Independence Service Central team to complete a Section 42 enquiry⁵ due to concerns of self-neglect, substance use, mental health and aggression towards others.
20. Throughout April and May 2023, Ahir’s GP made numerous attempts to contact Ahir via text, telephone call and offered appointments to review Ahir’s medication and discuss his blood pressure, but Ahir did not respond. Ahir’s family have told the author the last contact they had with Ahir was on 15th June 2023.
21. On 23rd June 2023, Ahir was sadly found deceased by his landlord at his home address.

(2) A PPN is an information-sharing document that records safeguarding concerns about an adult or child.

(3) DoLS are a legal procedure to protect people who lack capacity and are deprived of their liberty in care homes or hospitals.

(4) Section 9 of the Care Act 2014 requires a local authority to carry out an assessment, which is referred to as a “needs assessment”, the objective of the assessment is to determine whether the adult has care and support needs and what those needs may be.

(5) A Section 42 enquiry relates to the duty of the Local Authority to make enquiries, or have others do so, if an adult may be at risk of abuse or neglect.

Peter’s story

1. Peter was a 64 year old man of British heritage who lived alone in a council owned property. Peter was born in Southampton and was the youngest of five siblings. Peter’s niece recalls his love of music and has fond memories from her childhood of Peter watching snooker, playing games and rug making. The family experienced a number of bereavements and in Peter’s later years, his niece describes how he became “reclusive”. Contact between them significantly reduced, but Peter’s niece would still post a calendar through Peter’s door every year as she knew it helped him.
2. Peter had type 2 diabetes and a number of associated health issues related to this. He had poor mobility and experienced low mood. He had a history of previous drug and alcohol use.
3. In July 2021, Peter contacted his GP surgery stating he had bed bugs in his property. Prior to this, Peter had not been seen by a GP since 2019. A number of attempts had been made to contact Peter by letter, inviting him to a diabetes structured education programme, flu immunisations and COVID-19 vaccination, with no response. It is recorded that Peter did not have a phone or the internet.
4. In August 2021, Peter was sent a letter by his GP surgery as he was identified as a possible ‘ghost patient’⁶. Peter replied to the letter three days later confirming he was still at his address and still wished to be registered with his GP surgery. A GP appointment was arranged for Peter for 10th September 2021 which he attended.
5. Peter told his GP in September 2021 that he was depressed and “hoped to die soon”. He could only walk a short distance due to a diabetic ulcer on his left foot. Peter reported he was not taking any medication, including his diabetes medication. He had very dry skin and swelling to the left foot and leg. An urgent Podiatry referral was made by the GP. Peter stated he wasn’t drinking alcohol, but when he did he could consume a 70cl bottle of sherry in a day or sometimes make it last up to two weeks.
6. Transport for Peter was booked by the GP, but Peter missed his DVT (deep vein thrombosis) appointment later that week as he “did not feel up to it”. Peter received two home visits by the GP on the 20th and 21st September 2021 to discuss his non-attendance and any barriers to this. Peter reported he struggled to leave the house, in part due to bowel incontinence. He was unable to cancel or rearrange appointments as he had no phone and told the GP he was worried about getting a phone contract as he was unemployed. On the 21st September 2021, Peter was seen by Podiatry who record concerns for chronic neglect, but no safeguarding referral was raised.
7. At a GP appointment on 30th September 2021, Peter said he had no microwave, could not cook and had a poor diet. He told the GP he would like his life to end, but did not want to be fussed over.
8. In October 2021, Peter attended a number of face to face Podiatry appointments with the assistance of booked transport via his GP. On 1st November 2021, Podiatry raised a safeguarding concern regarding bed bugs at Peter’s property after seeing them on Peter. On 12th November 2021, Podiatry completed a safeguarding referral to ASC due to concerns for Peter’s hygiene, missed appointments and bed bug infestation. Podiatry followed up their referral on 18th November 2021 with ASC and updated ASC on a further missed appointment. ASC contacted Housing on 18th November 2021, Housing agreed to contact Peter to provide advice and support. It is not clear if this was achieved.
9. On 29th November 2021, ASC contacted Housing for an update. ASC flagged that Peter had missed two further Podiatry appointments and this may be linked to the bed bug infestation and not wishing to leave his property. It was also suggested that Housing may consider 60+ services for Peter. There is no recorded response from Housing.
10. On 30th November 2021, Podiatry contacted ASC following a letter from Peter that he no longer wished to attend appointments. ASC advised Podiatry that an assessment of Peter’s capacity would need to be undertaken before treatment was ended. Podiatry contacted Peter’s GP the following day and the GP made an urgent referral to CMHT on 8th December 2021. ASC closed the referral as there was no further role identified for them.
11. On 9th December 2021, CMHT informed Peter’s GP that Peter was not considered appropriate for their service, although the reason why is not recorded. On 10th December 2021, the GP undertook a home visit. Peter did not allow the GP in to the property. The risks associated with not attending Podiatry appointments was explained to Peter by the GP and Peter was deemed to have capacity from his presentation that day.
12. On 30th December 2021, Peter attended an Ophthalmology appointment. A safeguarding concern was raised to the VAST due to a heavy infestation of bed bugs and Peter’s unkempt appearance. Peter said he needed support at home. A referral was made to ASC who referred Peter to CMHT for consideration under S42 of the Care Act. ASC requested an urgent review of Peter’s care by CMHT, GP and Housing.
13. On 6th January 2022, CMHT visited Peter at home. CMHT were invited in by Peter, but due to the bed bug infestation they spoke with Peter on the doorstep. Peter felt the only problem he had was with the bed bug infestation and that Housing had agreed to attend his property when they were able to. CMHT concluded there was no mental health deterioration present and discharged Peter back to the GP on 11th January 2021. CMHT suggested that Peter may be open to advice and support for his nutrition as he was now experiencing consequences from his poor diet and physical health that he had not wished to address previously.
14. On 20th, 24th and 25th January 2022, ASC contacted Housing for an update on the bed bug infestation. An email was sent from ASC to Housing on 27th January 2022 requesting a call back. ASC emailed Environmental Health to see if they had any involvement with Peter (no response recorded) and Peter was allocated to the Locality Central Community Independence Service Team for an assessment under the Care Act. Peter was notified of this by letter on 14th February 2022 along with guidance on support services. However no contact was made by the Locality Central Community Independence Service Team until two months later despite Podiatry’s concerns that Peter was at high risk of abuse and neglect.
15. A further phone call was made to Housing by ASC on 8th February 2022, but this was also unsuccessful. On 10th February 2022, Housing received a report from the hospital regarding bed bugs falling off Peter and that these concerns had been raised multiple times over the last 5 months. On 23rd February 2022, Housing placed an order with pest control services for bed bug treatment at Peter’s property.
16. Following contact from Peter on 17th February 2022 requesting no further Ophthalmology appointments were booked for him, staff in the Ophthalmology Department wrote to Peter on 4th March 2022 outlining the risks that his vision was likely to worsen if he did not receive treatment.
17. ASC and the GP completed an unannounced home visit to Peter on 27th April 2022, but there was no response. After a further attempt, letters and phone calls, ASC contacted Housing on 25th May 2022 to ask if they had any recent contact with Peter, no response from Housing is recorded. A further unannounced visit was made by ASC on 26th May 2022, but there was no response from Peter. The case was discussed at an ASC team meeting on 1st June 2022 and closure agreed due to no safeguarding concerns and no engagement from Peter.
18. The GP sent two further letters to Peter in June 2022 that were not responded to. In October and November 2022, Housing sent letters and knocked on Peter’s door, but gained no response. A further visit was attempted on 3rd January 2023 with no response. In May 2023, twelve months after Peter had fallen in to rent arrears, Housing recorded that Peter was likely to be taken to court. There had been no update on the bed bug infestation and concerns for Peter’s health. Housing believed that Peter’s non-contact may have been due to suspected abandonment of his property. A referral was made to ASC by Housing on 30th June 2023 expressing a concern for welfare and flagging his non-engagement.
19. In July 2023, Housing were contacted by the Community Wellbeing Team with concerns Peter had not collected his medication for over twelve months. Housing contacted Peter’s GP to see if they had seen Peter, but this information could not be shared due to patient confidentiality. It was not explicitly recorded that Housing were concerned for Peter’s welfare.
20. The Community Wellbeing Team attempted to visit Peter on 17th July 2023, when they received no response they contacted police. Police officers attended and sadly found Peter deceased at his home address.

(6) A patient who is registered with a GP practice, but who has not accessed GP services for some time. This may be as they have moved area or passed away, but the GP practice have not been notified.

Needs, safeguarding, engagement

1. Multiple presenting needs

   “He just didn’t get the help he needed when he really needed it”

   Ahir and Peter presented with ongoing physical health needs. In Peter’s case, this appeared to impact on his mental health and having “no love for life”. Both men expressed they hoped they would die and that they struggled to leave their homes. Ahir was drinking heavily at times and Peter disclosed to his GP that on occasion he would drink a 70cl bottle of sherry in a day. The true picture around Peter’s alcohol use was not known by any agency and Peter did not come into contact with CGL during the review period via agency referral or self-referral.

2. There was evidence that attempts were made to medically address Peter’s physical health needs, but it was not entirely clear if there were any conclusions reached about his physical and mental health needs being interrelated. It appears that mental health services were limited in what they could provide Peter. There was no record of a formal diagnosis of any mental health condition for Peter.

3. Ahir was also referred to mental health support services, but deemed not to meet the criteria and discharged back to his GP. There appears to be a focus on addressing his alcohol use through engagement with CGL in the first instance.

4. At the practitioner workshop, agencies reflected on having little knowledge of who else was involved with Ahir and Peter. There was a lack of ownership and coordination in Ahir and Peter’s care, with the responsibility of onward signposting often falling on Ahir or Peter’s GP.

5. Agencies at the practitioner workshops felt that Ahir and Peter may have benefitted from application of the Multi-Agency Risk Management (MARM) framework. The 4LSAB MARM framework has been updated since the passing of Ahir and Peter and the four LSABs have widely promoted that a MARM meeting can be called and led by any agency. SSAB have also produced a number of resources to aid professionals in calling and chairing a MARM.

   Question for the board: Is the board satisfied that all partners are giving equal consideration to raising a MARM?

6. Fluctuating or perceived non-engagement

   “He was registered with so many services but no-one helped”

   There appeared to be times when Ahir and Peter disengaged from services, but the reasons for the perceived disengagement were not explored. Given the complexity of Ahir’s and Peter’s needs, they may have benefited from services offering support in different, flexible and more assertive ways.

7. The time period examined also included months when there were COVID-19 restrictions. Ahir and Peter both reported not having access to the internet which would have limited their ability to engage with support. Some agencies found success with writing to Peter and texting Ahir, but this information was not always shared between agencies to promote what communication methods were working for each of the men. This may have resulted in missed opportunities to see Ahir and Peter in person and to form an objective opinion on their health and wellbeing at earlier stages. It doesn’t appear that any professional saw Ahir or Peter inside their homes after COVID-19 restrictions ended in 2021. This period of restrictions and increased isolation during the pandemic may have exacerbated their self-neglect and subsequent living conditions. Attempts were made to visit Peter at home, but he either declined entry or professionals did not enter due to the reported bed bug infestation.

8. At the practitioner workshop, agency representatives felt that guidance for professionals working with adults who may not be engaged with support on offer, would be useful. This guidance should prompt practitioners to rethink the risks and concerns prior to closing a case; to discuss that decision with a supervisor; consider arranging a professionals meeting to ensure all agencies are communicating and sharing information; and consider escalating concerns via a safeguarding referral or the 4LSAB Safeguarding Adults Escalation Protocol if there is professional disagreement on what should happen next.

   Question for the board: Would the board consider producing multi-agency guidance for working with adults who may not be engaged with offered support?

   See: Guidance for Working with Non-Engaged Adults (Calderdale Safeguarding Adults Board)

9. At the practitioner’s workshop, agencies discussed the importance of the language used by professionals working with non-engaged adults. Recording that a vulnerable adult ‘did not attend’, without exploration as to why, may lead others to view that adult as not engaging. There was additional discussion around the stigma associated with individuals who use substances or experience self-neglect that they are making a ‘lifestyle choice’ and how this in turn may impact on professional’s persistence to engage the adult. At the practitioner’s workshop agencies discussed unconscious bias⁷ and that this bias may have reduced professional curiosity. This is learning identified in another recent Southampton SAR⁸.

   Question for the board: Does the board see benefit in producing a public communication campaign, similar to the NHS ‘Stigma Kills’ campaign that focuses on how perceptions, actions and words can reduce vulnerable adults accessibility to services?

   See Stigma Kills Campaign (NHS Addictions Provider Alliance)

10. There was evidence of professionals recognising ‘windows of opportunity’ with Ahir and Peter to re-engage them in services. Although this largely stemmed from Ahir or Peter making contact with support services themselves, professionals used that opportunity to offer face to face appointments (Peter’s GP) and engage Ahir with support groups (CGL). This was considered good practice and elicited a positive response from Ahir and Peter.

11. Safeguarding

    “We were made to feel that he was just another number and his life wasn’t important”

    It was not always explicitly identified that Ahir and Peter were experiencing long term self-neglect. There was good evidence of agencies raising safeguarding concerns for both Ahir and Peter, but agencies were rarely working together.

12. SSAB have produced self-neglect guidance for professionals to aid identification of self-neglect indicators following recommendations made in previous Southampton SARs⁹.

    Question for the board: Is the board satisfied that the SSAB self-neglect guidance is suitably robust to respond to high-risk self-neglect when services have difficulty in achieving engagement with the adult?

13. There were a few occasions when the MCA was used during the review time period, but agencies at the practitioner workshop felt there was still a lack of confidence amongst professionals in this area and a misunderstanding around both decisional and executive capacity and that mental capacity is both decision and time specific.

14. Furthermore, substance use, physical health needs, poor nutrition and self-neglect can impact on cognitive impairment and capacity. There is reference to considering Peter’s capacity when he informed services he no longer wished to attend his health appointments. This was completed on the doorstep by his GP, but no formal MCA assessment was requested. Assessing capacity is centrally important in managing type 2 diabetes, as type 2 diabetes itself is associated with a range of factors which directly impact capacity¹⁰.

15. An MCA assessment was completed for Ahir when he was in hospital and he was found to lack capacity and placed on a DoLS. Following his discharge from hospital in September 2022, Ahir’s GP and CGL attempted contact with Ahir, but gained no response. No agency had any contact with Ahir until his family raised safeguarding concerns for him in February 2023, five months after his hospital discharge, in which his property was reported to be in a poor condition with food and rubbish on the floor. Ahir was missing his medication, not eating properly and not using the heating.

16. Other Southampton SARs¹¹ have questioned the effectiveness of the application of the MCA which resulted in a programme of work by SSAB to raise awareness of the MCA, providing practitioners with clear guidance on the legislative duties and responsibilities placed upon them and promoting the MCA Toolkit.

    Question for the board: What measures can the board take to support practitioners in working with executive capacity? Should partners commission additional training and guidance for frontline staff on this issue?

17. Ahir and Peter’s voices and wishes

    "If agencies had worked with the family and not just the individual the outcome could’ve been very different”

    Ahir and Peter would have benefited from services trying to understand the underlying reasons for their self-neglect, mental health concerns, substance use and fluctuating engagement. There was some evidence of Ahir and Peter’s voice and wishes being captured, but this was not analysed to understand why they felt that way or pursued in an attempt to resolve what Ahir and Peter perceived they needed.

18. Peter repeatedly told agencies about the bed bug infestation in his property. Safeguarding concerns were appropriately and tenaciously raised by several agencies (Podiatry, Ophthalmology and ASC) and Housing were contacted, but pest control were not notified until five months after the initial concern was raised. No preventative course of action or treatment was taken for the bed bug infestation whilst Peter was alive. Some agencies identified that the bed bug infestation may have limited Peter’s desire to access public services and it prevented agencies from entering his home to gain a true picture of Peter’s life and how he was living. Peter indicated this was his main concern.

19. At the practitioner workshop, it was established that any agency could have made a referral to pest control, but these concerns are often directed to Housing as there is a fee that is incurred. In turn, this fee is the resident’s responsibility, which poses a further barrier for someone like Peter who was already experiencing financial difficulty, had no cooker, fridge or microwave, wasn’t eating well and felt unable to commit to a phone or the internet due to his financial circumstances. Agency representatives also reported that they rarely received any feedback after any safeguarding referrals were submitted which meant agencies were unsure if anything needed following up or further action taken. This was not specific to Ahir and Peter and was seen to be a wider practice issue for cases where there is a lack of ownership and coordination in a vulnerable adult’s care (see 8.4).

20. Ahir had an extensive history of trauma, yet it wasn’t clear how trauma-informed agencies had been. The family informed the author that Ahir could only maintain one relationship with one person at a time, which agencies did not appear to be aware of. There was also little reference to Ahir’s culture, heritage or religion despite it being recorded that Ahir attended a place of worship. There may have been a missed opportunity to establish if Ahir was gaining any support from his faith community or if this is something that could have benefitted Ahir with his social care needs. English was not his mother’s first language, indicating possible second generation migration and social considerations that may have been missed by agencies.

21. Ahir’s family informed the author that Ahir was Sikh, but largely non-practicing. They stated that there is a stigma attached to mental health in Asian culture that may have been a barrier to Ahir accessing support. In addition, Ahir’s alcohol use was not seen as problematic by the wider community he had contact with as alcohol is seen as part of cultural celebration and can become a social norm. Recognising cultural context is previous identified learning from two recently published Southampton SARs¹².

22. Making safeguarding personal and ensuring actions are sequenced in a way that evidences the individual’s wishes and views are at the centre of decision making, enhances engagement, empowers the individual and shifts the focus on to the person and not the process.

23. A number of agencies had contact with Ahir’s family throughout the review period, but there was little evidence of persistence in seeking consent from Ahir and Peter to contact and involve their families, friends, or anyone else who may have supported them. Several agencies reported being unaware Peter had a next of kin as they believed he had no contact with his family. Ahir’s family made contact with agencies in attempts to gain suitable support for Ahir as they felt unable to continue to care for him. However there was often no follow up on agreed actions by agencies and when the family enquired about the actions, they were informed a record of their previous conversations with agencies could not be found. There was no agreed single point of contact in the family, which resulted in information not always being known by the family member who could support Ahir at that moment in time. There was also little evidence of signposting Ahir’s family to support for themselves and no recognition of Ahir’s family providing caring responsibilities.

24. At the practitioner workshop, agency representatives discussed the 4LSCB and 4LSAB Family Approach toolkit. It was felt that there has been strong promotion of the ‘Family Approach’ and this was well understood by professionals, however this approach may not accurately reflect the response needed for vulnerable adults like Peter who do not have family involved in their day to day care.

25. Appointing an advocate for an individual may increase the potential for professionals to engage with a vulnerable adult and ensure that their voice and perspective is heard. The different types of advocacy are outlined in the 4LSAB Adult Safeguarding Policy, Process and Guidance.

    Question for the board: Is the board satisfied that partners are aware of the different types of advocacy and that practitioners feel confident in raising the need for statutory advocacy in cases where it may otherwise be overlooked?

(7) Unconscious bias refers to a bias that we are unaware of and which happens outside of our control. It is a bias that happens automatically and is triggered by our brain making quick judgments and assessments of people and situations, influenced by our background, cultural environment and personal experiences.

(8) Anna (2024) and Gianbir (2024)

(9) Nicola SAR (2023) and Gianbir SAR (2024)

(10) Self-management interventions for Type 2 Diabetes: systematic review protocol focusing on patient workload and capacity support

(11) Louise SAR (2022) and Gianbir SAR (2024)

(12) Anna (2024) and Gianbir (2024)

Appendix

Glossary