Opportunities missed to intervene and prevent death of vulnerable adult controlled by 'friend' says report

Published by Professional Social Work magazine, 10 August, 2023

The Mental Welfare Commission in Scotland has said “no effective intervention” was made to help a vulnerable person who died despite concerns about them being controlled.

An investigation by the commission has led to a series of recommendations, including training for social work and health staff to better identify adults at risk.

The commission's findings come as the Westminster government made a series of recommendations - including considering following Scotland by giving England social workers powers of entry in a review looking at how to better safeguard adults from abuse involving people close to them.

In the Scottish case the individual, known as AB, was a middle-aged adult with learning disabilities and physical health issues who had been under the influence of another person, CD, for several years. CD is described in the commission’s report as a “friend” who “presented variously as a relative and carer while AB was in hospital” and in dealings with authorities.

The behaviour of CD caused concerns at hospital during more than one stay – CD interfered with AB’s treatment, and encouraged AB to refuse care.

CD had instructed a solicitor to legally challenge the involvement of social workers and healthcare professionals, and to attempt to revoke a detention certificate issued for AB’s protection in 2016.

Hospital staff noted that AB would be “more hostile and resistant to care” after visits from CD.

The final hospital admission was in 2019, when AB was admitted following a fall resulting in a “debilitating fracture”. Recovery “was compromised” and AB died in an orthopaedic rehabilitation ward from organ failure secondary to sepsis associated with skin ulceration.

Just before AB’s death, CD was charged with culpable and reckless conduct towards AB while in hospital, a charge that was subsequently dropped due to lack of evidence to support criminal intent.

No Significant Adverse Event Review (SAER) or Significant Case Review (SCR) was carried out after AB’s death.

Investigation

The Mental Welfare Commission led an investigation into the death of AB amid concerns over deaths of people with learning disabilities.

AB was detained under the Mental Health (Care and Treatment) (Scotland) Act 2003 for a number of weeks until the day before their death and was also subject to Adult Support and Protection (Scotland) Act 2007 procedures.

The report states there were “multi-agency” concerns about the influence AB was under at the hands of CD, and the commission concluded action could have been taken to put protections in place.

Access to health services and treatment was restricted despite family, social workers, health workers and others raising concerns. There were three adult support and protection investigations and two periods of detention in hospital under the Mental Health Act in the five years before AB's death. But the report states: "Despite opportunities, no effective intervention which would have changed AB’s circumstances was made."

AB’s family told of “the marked change” seen in AB after coming under CD’s influence and leaving their home area. They tried to reconnect with AB but were unsuccessful. The report continues: “They described their concerns about AB’s treatment and care. They found it difficult to understand why CD was so readily accepted as AB’s carer and that they were not consulted.”

Suzanne McGuinness, executive director of social work for the commission, said: “This is a very distressing case, where a vulnerable person was isolated from their family by another individual over many years, to their personal detriment.

“It resulted in increased poor health and an early death. Despite opportunities, no effective intervention which would have changed AB’s circumstances was made.”

The purpose of the commission's review was to examine the care AB received and analyse their limited engagement with services. The aim was to identify if systemic failings could have contributed 'directly or indirectly' to their death.

The ten main findings were:

• A welfare guardianship may have made it possible "to more effectively balance protecting AB and supporting AB and CD”
• More could have been done to protect AB's safety during inpatient stays
• Problems with engagement may have led decision-makers away from guardianship processes and capacity assessment of AB
• No learning was taken from previous admissions, putting AB at “unnecessary risk”
• There was sufficient evidence for a welfare guardianship order in 2016
• The inability to find a second doctor was a “system failure”
• CD's appointment as power of attorney could have been challenged
• There was “little recorded discussion” of the concept of undue pressure
• There was a lack of working knowledge among professionals on Mental Health Act legislation
• A significant case review should have been carried out

Report recommendations include:

• Training and support for social work and health staff on adult support and protections, including identifying an adult at risk when in hospital
• A review of processes within the local authority and NHS on when to initiate reviews
• Ensuring staff are aware of the role of the Office of the Public Guardian, who can be alerted about an attorney and revoke a power of attorney order
• A nominated lead for cases where there is inter-agency complexity and multi-site treatment provision
• Better risk management planning in case management arrangements
• Better auditing of effectiveness of processes relating to people with learning disabilities
• A review at government level of obtaining second medical reports for guardianship orders
• Improvements in processes and monitoring speed of access to medical reports across health and social care

McGuinness added: “We hope this in-depth report will help raise awareness of the importance of identifying where undue influence may exist and the legislative frameworks which can be used to avoid similar situations in future.”

The case in detail

AB became estranged from their family in the 1990s and left their home area with CD, who acted as AB’s relative and carer in dealings with authorities.

An initial Adult Support and Protection (ASP) investigation in 2014 was closed because attempts at making enquiries were “limited”, and a letter was sent to family advising ‘no acute concerns’.

A second ASP investigation into AB was run in 2015 and 2016 after concerns were raised by a second individual, XY, who CD was also claiming to be carer for.

Like AB, XY had cut ties with family.

The second ASP investigation concluded that AB was a “vulnerable adult who might be unable to safeguard themselves and was at risk of harm.”

But AB’s deteriorating physical health meant a planned unannounced home visit – with the aim of arranging a removal order – never took place, and AB was urgently admitted to an acute high dependency unit in hospital.

Staff on the unit “expressed concerns about CD’s odd and sometimes hostile behaviour”.

CD brought in unsuitable food, brought their pet into the ward and encouraged AB to refuse personal care.

An emergency ASP professionals meeting agreed further assessment was necessary given evidence of apparent neglect or self-neglect.

Plans were developed for AB’s admission to the local psychiatric hospital and they were admitted to the hospital learning disability unit under a short-term detention certificate (STDC).

A solicitor engaged by AB and CD challenged the need for visits by social workers and the grounds for questioning CD’s care of AB. The solicitor made a formal complaint about the admission, and appealed the detention certificate, although this was unsuccessful when heard by the Mental Health Tribunal.

Ward staff observed AB was more hostile and resistant to care after visits from CD. A case conference considered a compulsory treatment order (CTO) or a guardianship order.

AB’s lack of capacity was noted. But the inpatient team also identified “potential risks to AB if separated completely from CD”.

Joint living with a degree of supervision was felt to be “the best way forward”.

Various failings meant AB remained under the influence of CD.

• CD was not removed as ‘named person’ under section 255 of the Mental Health Act
• A second medical opinion could not be obtained for a welfare guardianship application because AB would not speak with a visiting GP and “the ward junior doctor was inexperienced”
• AB’s care plan once discharged was found to be not working
• Despite meeting criteria as “an adult at risk of harm” AB was discharged from ASP, the guardianship application was suspended, and the case was moved to multi-disciplinary review under the Care Programme Approach (CPA)

The report states: “The view was it was better to maintain supervision of AB’s circumstances in a low key way involving fewer rather than more professionals. Neither AB nor CD attended any CPA meetings and their solicitor continued to correspond with social work on their behalf saying they felt hounded.”

AB’s case was closed by social work in the middle of 2017.

Just over a year later, AB was admitted to the acute hospital orthopaedic ward after a fall resulting in a fracture. They were moved to an orthopaedic rehabilitation hospital. AB objected to the transfer and refused to be assessed.

By this time CD was AB’s financial and welfare power of attorney.

CD “frequently removed AB from the ward and AB missed out on opportunities for physiotherapy. Interference with AB’s medication and physical healthcare also occurred, although it remained uncertain who was responsible for this”.

Towards the end of 2018, AB was detained under a STDC because of a deterioration in their physical and mental health.

By early 2019 AB was admitted to hospital, made a specified person under the Mental Health Act, and visiting restrictions were imposed on CD - evidence continued to emerge that CD was interfering with AB’s treatment.

An application for a compulsory treatment order (CTO) was granted a month later, and a local authority guardianship application was granted five days before AB’s death.

AB’s family were with AB in their final days having been contacted by social workers.

The police were involved in all three ASP investigations and in the last few days of AB’s life took CD into custody.

After AB’s death, the procurator fiscal decided against prosecuting CD on charges of culpable and reckless conduct due to insufficient evidence of criminal intent. No significant adverse event or significant case review was carried out locally.