Serious Case Review Final Report for the Dudley Safeguarding Vulnerable Adults Board Re: BD 1. Purpose of the report
1.1 This report has been produced in line with the revised terms of reference set by the
Sub-group following the death of Mr BD. Based on 12 reports provided by a range of partner agencies it analyses the separate and combined contributions each made to the care and support of BD in the years preceding his death. It comments on aspects of some agencies involvement and of the quality of partnership working that supported Mr BD. Finally it recommends key changes in policy and practice which should increase the likelihood of more systematic, co-ordinated and, above all, proactive intervention when confronted in future with such a challenging and vulnerable individual.
2. Overview
2.1 BD was at the time of his death 39 years old. He was found dead at his flat alone on
Monday 29th June 2009. He was of Asian origin. Although without a formal mental
health or learning disability diagnosis, he was frequently assumed by professionals and presumably others as having one, the other or both. There is evidence that he had the capacity to make informed decisions about his lifestyle.
2.2 The cause of his death was formally recorded as accidental following injuries
almost everybody he had contact. There is no evidence that BD wished to address the alcohol dependency problems that he had. Indeed there is substantial evidence to demonstrate that he was frequently offered help and equally frequently rejected it.
2.3 There is considerable evidence that demonstrates BD was regularly offered and
rejected support by many individuals and agencies and in particular health care staff. On the basis of this it is not unreasonable to conclude that whatever more might have been done BD would have more than likely rejected every attempt to assist him. However, opportunities were missed to support BD. The most telling failure of a number of agencies was not to realise this man was vulnerable. What is most apparent is that despite so much time being spent on him by so many agencies the degree of his usage of health, social care, emergency and probation services did not come to light fully until after his death. Had public agencies recognised more quickly the degree of BD’s vulnerability they might have been able to intervene more effectively and in better in supporting him and might have deflected him away from a self-destructive lifestyle. His constant and inappropriate use of emergency and health services inevitably led him to be seen by many hard-pressed front line staff as a nuisance and a time waster. What agencies generally failed to do was to stand back and analyse what the frequency of his demands might mean. Had any one agency pieced together the complete picture from all they would have realised that he was one of the highest users of the police, ambulance and hospital accident and emergency services.
2.4 It is possible that a greater and earlier emphasis on BD’s cultural and religious
background might have brought additional influences to bear to help him understand and possibly address the difficulties he was experiencing. There were opportunities to recognise that attacks against BD’s property might have been motivated by racism or his perceived disability.
2.5 The Probation Service were statutorily involved with BD on three occasions in 2004,
2005 and 2008. At the time of writing the service has been unable to provide any information about the first two occasions. This is a matter of concern. Despite the Courts recognising this man’s criminal and alcohol related behaviour warranted formal supervision. These opportunities to address the combination of personal vulnerability, antisocial behaviour and habitual non-compliance with those trying to help him, appears to have been missed.
2.6 It is important that the shortcomings in the actions of individual agencies’ response to
BD are addressed. In particular there is an urgent need to ensure partners better identify vulnerable individuals and, by combining their total knowledge, take co-ordinated action to address the needs identified. In so doing it will assist in ensuring that every opportunity is taken in future to assist people who are motivated to address their problems and vulnerability.
3.0 The significance of BD’s dependence on alcohol and its implications for assisting him
3.1 The references to BD’s excessive alcohol consumption are evidenced in most reports
3.2 The report from the Dudley Group of Hospitals refers to the frequent and sustained contact they had with him which lists 109 attendances at Accident and Emergency in a period of less than ten years. Although not all were alcohol related 27 specifically mention this as the principle reason for the contact. As far back as 2006 BD’s alcohol consumption was described as being 112 units per week. The following observations from the records of other agencies further illustrate the significance of alcohol in BD’s life and how it impacted upon him.
3.3 The PCT report evidences a GP referral to Aquarius in 1999, and a referral to the GP
from Russells Hall Hospital on 20th June 2006 which describes BD as ‘invariably
intoxicated.’ It is worth noting this date and reference does not appear in the Dudley Hospitals report. The PCT chronology, commencing in 1996, makes 33 references to alcohol. There were eight recorded occasions when BD was advised to stop drinking. Typically these requests were specifically rejected and it corresponds with a pattern of failing to engage with much support that was offered. There were 20 references to failing to attend appointments or refusing to accept medical advice. He was twice referred to the Alcohol Liaison Team.
3.4 The GP’s report from his GP states: ‘From 1996 onwards my impression is that he
had become addicted to alcohol and had stopped maintaining a healthy diet.’ In December 2008 he said: ‘I pleaded with him to reduce his alcohol intake and seek help and support from Aquarius – he again refused...’ Finally he states: ‘Throughout all of this period BD refused to change his lifestyle and continued to drink heavily.’
3.5 The Mental Health Trust report, covering the period 1992 to 2009, makes 11
references to excessive alcohol consumption and four times talks of his denial of the significance of this and his refusal to accept any help. In 2007 a substance misuse Community Psychiatric Nurse (CPN) was involved.
3.6 The four safeguarding strategy meetings arranged by the Adult Social Care
Safeguarding Coordinator all refer to issues of alcohol or substance misuse.
3.7 According to Police records mentioned at the first conference BD’s drinking problems
go back to 1998.
3.8 During the period of BD’s probation supervision the service attempted to involve an
alcohol intervention worker with him.
3.9 Alongside this accumulated evidence of alcohol misuse and dependency there is
similarly strong evidence of BD’s refusal to accept help. Not only are there examples in the text above there are similar descriptions elsewhere in the management reports. The Housing Department talked of his ‘reluctance to engage’ and Centre for Equality and Diversity said that BD requested no further action from them after some initial advice and representation.
3.11 A neighbour reported that BD used to lie in the middle of the road waiting for an ambulance that had been called to assist him. A driver had taken him back to his flat 5 times but each time BD returned to lie in the road in front of the car.
3.12 According to information available to a multi-disciplinary conference, by October
2007 the Police had a record of BD making 320 emergency 999 calls and had been
charged for misuse of the service. In one day in 2004 Mr BD had made 111 emergency calls to the ambulance service alone. On more than one occasion he was prosecuted for misuse of the emergency call and action was taken on more than one occasion to effectively bar his phone.
3.13 A mental health day centre that BD attended banned him on more than one occasion
because of his disruptive and aggressive behaviour.
4.0 Areas for improvement
4.1 There are a number of areas where it would appear more might have been done.
The key areas are listed below and are in no particular priority order.
4.2 Record Keeping and Reporting
4.3 Most agencies have had some difficulty in constructing a retrospective chronology of
their involvement with BD. In the case of the Probation Service their initial report for the sub-committee failed to refer to two of the three occasions BD had been subject to a court-imposed order and have still to produce any information about them. In the case of the Mental Health Trust three different services who worked with BD – Woodside Day Service, the drug and alcohol service and the psychiatric in-patient services. However there is little evidence to suggest that the services of the Trust worked together or maintained a co-ordinated record of their involvement.
4.4 In any multi-agency attempt to support an individual it can be difficult to provide
co-ordinated assistance. It becomes even more so when agencies cannot individually evidence what they have done, when they have done it and what effect it had. If better records had been kept there would have been an improved chance of recognising the depth of BD’s problems probably causing alarm bells to have sounded earlier. If so, concerted efforts to support him would have been potentially more effective and commenced sooner. Examples are given below:
4.5 The Centre for Equality and Diversity did not maintain any official record as BD did
not wish to receive their support in relation to an alleged assault from young people in the local community. Despite this lack of official involvement the Centre attended case discussions, wrote a letter on BD’s behalf and was involved with him for at least 12 months beyond the date that their management report indicates.
4.6 The Housing Management report acknowledges there are no records of a meeting
4.7 An assessment was requested from Autistic Spectrum Conditions team through the Community Learning Disability Team (CLDT). A reference to this was entered on the case notes and a request for this to be followed up was placed in unofficial communications book but not confirmed by memo or email. The referral was never actioned.
4.8 There were significant omissions in the initial Mental Health Trust management
report which indicates that their records may be incomplete. The examples below are issues that were referred to in other agencies’ reports but not mentioned in their own.
- GP records from 15th August 1998 indicate BD was referred to Woodside Day
Centre although there is no copy of any letter sent.
- In September 2004 the Police report refers to a planned joint visit to BD with
colleagues from the mental health services. The mental health service makes no reference to this and Police records make it clear they are unsure whether the planned visit actually went ahead.
- On 20th October 2000 the Older People’s and Physical Disability (OPPD)
team passed information about BD to Duncan Henderson – Mental Health Team Manager to organise a mental health assessment for BD on his discharge from Russells Hall Hospital.
- On the 24th June 2006 Paul Smith of the Woodside Day Centre referred BD to
the OPPD team. He requested a Case Conference as he feared BD ‘..is going to do himself damage.’ He was advised to contact the Alcohol Team. There is no evidence supplied to confirm this was done.
4.9 In March 1999 a referral was made to the Adult Care Team which revealed that BD
was ‘sectioned three years ago.’ According to the Mental Health Trust the admission in 2006 was informal not compulsory.
4.10 The involvement of the Safeguarding Team was not recorded on the Adult Social Care’s computerised record system SWIFT. This meant that interrogation of the database from other social care teams or enquiries from other agencies would not have revealed the concerns about BD and how they were being managed.
4.11 The PCT report refers to a GP discussion with a social worker on the 5th February
2006. No name is given and there is no corresponding reference in adult social care management reports. GP records are often unclear about the specific action taken in response to an identified issue nor are always clear whom a referral was given to.
4.12 At the Adult Protection Conference on 30th October 2007 Dr Cartwright maintained
contacts BD had with the Dudley Hospital Trust may have been even higher than their report suggests
4.13 The West Midlands Probation Service has been unable over a two month period to
produce any information about its two first periods of statutory intervention with BD. As such this report cannot comment on their total involvement and its significance.
4.14 Management Co-ordination and leadership
4.15 There is evidence that better management of BD’s situation and ownership of responsibility for him would have created further opportunities to support him. The impact of having no clear managerial oversight is illustrated below:
4.16 On 1st April 2008 the Director of Adult Community and Housing was personally
lobbied by family members on behalf of BD. She indicates in her email to the assistant directors for housing and for social care her expectation that: ‘a cross-service multi agency approach will be followed in reviewing this case.’ What was less clear was how this would be monitored to ensure it happened. It was of concern that there was no manager within adult social care with an allocated responsibility for BD. The Safeguarding Manager convened conferences to discuss his circumstances and appeared to have a co-ordinating brief but did not have operational responsibility for him. From discussions with the Assistant Director and representatives of the mental health trust it is clear this responsibility should have rested with the mental health social care team manager. Had this been clearer, operational responsibility for follow-up following BD’s move would have also been clearer and more likely to have happened. Although an offer of alternative housing came quickly after this intervention the necessary co-ordinated support both during and following his move was less apparent. For example the support package considered by all agencies
present at the conference on the 17th October 2007 did not in effect materialise. An
assessment which was agreed to be completed by the Autistic spectrum Conditions Team in December 2008 never took place due to an oversight. Even when this was
brought to the attention of the Safeguarding Manager on the 1st of June 2009 – less
than a month before BD’s death – there is no evidence to determine whether this was still relevant.
4.17 Both the mental health and Dudley hospitals trusts had abundant evidence to demonstrate that BD had a chaotic lifestyle and both frequently and often inappropriately sought help from them. However, at no stage did either agency review the implications of his almost constant demand for help and take a proactive approach to identifying his needs and clarifying who might else be seeking to help him. In particular in the Dudley Group of Hospitals report to the Safeguarding Sub committee they recognised this shortcoming and were taking steps to address this through changes in their policy and practice towards frequent attendees.
There are illustrations of this in relation to the Netherton District Office. On four occasions within eighteen months the team were asked to take responsibility for BD. Each time they advised the referrer to seek help elsewhere. Whilst this might have been the correct response, at no point did team members identify that there was a problem that nobody seemed to be owning and taking responsibility for finding a solution.
4.19 Throughout the two housing conferences and the four safeguarding conferences are
examples of actions that were to be pursued by various teams and agencies but there is evidence that not all of them were. For example a proposed visit to BD by a member of the Substance Misuse Team –recommended at the adult protection
conference on 30th October 2007 – seems not to have taken place. Similarly at the
conference in August 2008 it is stated that the Police Vulnerable Person’s Officer would monitor and report on an anticipated court appearance for BD in October of that year. There is no evidence so far to suggest this was done. Had it been the Safeguarding Manager would have been aware of the Court Order that was made and might have effectively contributed relevant information to the allocated probation officer. As it was a team in adult social care, who had no knowledge of previous case conference activity, became involved with the Probation Service.
4.20 The West Midlands Police service’s report is particularly self critical of its local officers persistent failure over many years to recognise that BD’s constant bombardment of 999 calls and officer visits indicated his vulnerability rather than just a nuisance. As early as 1989 they now recognise that there was an emerging picture of him having quite complex welfare needs but that no action was taken to address this. As early as 2002 and on a number of other occasions the Police failed to distinguish between BD’s unreasonable and demanding behaviour and his underlying need for help. They now recognise in retrospect that he had a legitimate cause to contact their services and that some of the alleged crimes he reported went uninvestigated and often were not even identified as a crime in the first place. One of the major criticisms the Police now recognise of their own practice was that police operators were inconsistent in how they managed BD with some closing logs, and others considering telephone disconnection as a response to his constant misuse of the service. Underlying this was the almost complete failure to recognise in over five years of substantial contact with BD that he might be vulnerable and need a proactive approach to address his constant demands.
4.21 A number of recommendations in their report address the issues they have identified
in relation to identifying people who are thought to be vulnerable reviewing those who make excessive use of the 999 emergency and other police services.
4.22 The examples above illustrate a few of the many opportunities missed by agencies,
neighbourhood he lived in and the degree of harassment he was subject to. Once he had moved and was seemingly more content – evidenced by a significant decline in misuse of emergency services for a while - he might have been better disposed to the support of many that he had previously rejected. Although this was still something of a long shot, an opportunity was missed.
4.23 The oversight and co-ordination of one senior manager linked to clearer multi agency
allocation of responsibilities would have significantly improved the chances of successful support for BD. In a future case, with a person more amenable to receiving support, such co-ordination could make the difference between life and death.
4.24 Identifying somebody as vulnerable
4.25 The learning point in two management reports was about improving staff understanding of who might be vulnerable and then taking appropriate action to support them. I would concur with this view. With more awareness of these issues within the PCT and Dudley Hospitals it would have been more likely that action would have been taken to act on the evidence of a clear pattern of behaviour that pointed to BD’s vulnerability. Similarly the Probation Service has recognised it might have taken additional steps to support BD in partnership with others. Potentially the additional leverage that a Community Order brought created the best chance of successfully intervening to break the downward spiral he appeared to be on. A referral to the Adult Safeguarding team prior to the probation order lapsing might have changed matters for the better, although it is acknowledged BD’s previous history makes this possibility remote. Any referral by Probation to another social care team would not have been as effective due to the recording failure mentioned on page four of this report.
4.26 To address these concerns The Safeguarding Board needs to consider how all partners agree which of their staff require training that will help them successfully recognise who might be vulnerable. Furthermore agreement is needed on knowing how to respond to situations where people are deemed vulnerable in line with agreed joint procedures. Of equal importance is to ensure that there are effective plans in place to deliver the necessary training to all who require it within agreed timescales.
4.27 Focus of Intervention
4.28 The management reports emphasis that different agencies had differing focuses for
their intervention. For the health and Police services the approach was essentially reactive responding to the many crises that BD presented to them. His refusal to address his underlying difficulties and alcohol dependency made it difficult to do otherwise. For the housing and safeguarding teams the intervention in 2007 was essentially around housing and helping BD extricate himself from a hostile environment which he appeared to have partly created himself.
4.29 In general agencies did not recognise any racial, cultural or religious elements to the
2007 and the assistance of the Centre for Equality and Diversity was sought. By 2007, when this was first considered Mr BD was not wiling to engage with officers of the Centre for Equality and Diversity. Had there been an earlier multi-agency approach it might also have been possible to engage appropriate community resources including family or place of worship.
4.30 In 2007-08, at the height of BD’s difficulties, when neighbour disputes and break-ins
to his home frequent, nobody in the Police Force seemed to consider the possibility of these being categorised as a Hate Crime. It was in July 2007 that such issues gained a particular national prominence following the convictions that month of a number of people of killing Stephen Hoskin, a disabled man, in St Austell Cornwall. Had BD’s problems at this time been recognised in a different light the response to him would also have been different.
4.31 It is unclear precisely what the longstanding role of the mental health services day
centre was. It is indicated that it was a means to try to help him retain a social life and support him address the domestic and behavioural issues that featured heavily in his day to day life. It is less clear whether there was a specific assessment and a resultant care plan to guide and evaluate intervention. Similarly there was no assessment to establish the interrelationship of personal and family issues with the two longstanding health problems, epilepsy and alcohol dependency. Through the safeguarding process it could and should have been possible to arrange for a thorough multi-disciplinary assessment and ensure that all agencies combined to offer a more integrated approach to the challenges he clearly presented. In essence once an adult has been identified as vulnerable there needs to be a process in place that ensures an assessment is attempted.
5.0 Recommendations
5.1 Many of the individual agency reports that have informed this analysis have included
recommendations for their own agency. This report represents the key findings and issues for the partnership as a whole. There is nothing particularly new or surprising in what has been identified and similar issues can be found in many other retrospective enquiries where it appears that something has gone wrong.
5.2 It is relevant to mention the context within which health, social care and emergency
services are delivered. All these agencies are extremely busy and have a constant battle to address immediate demands. It is perhaps unsurprising that one of the key issues for this report was the lack of a more considered approach to BD’s problems. In the main agency responses were reactive and often failed to look at the pattern of demands he was making on each individual agency and not recognise the demands made on the whole partnership. It is within this context that acts of omission occurred. The Police, health and social care services all recognise they individually could have done more. Once a revised report is received from the West Midlands Probation Service a similar message may well come from them.
5.3 Over and above the recommendations and actions outlined by individual agencies
It is far from certain that, even if everything that could have been done had been done, BD would have been alive today. However the implementation of these recommendations will significantly reduce the likelihood of somebody else in similar circumstances suffering the same end.
Recommendation 1 - Record Keeping
The Safeguarding Board should use its influence to ensure that all agencies have record keeping systems where it is possible to capture the totality of the work they are or have been doing with any individual.
It is clear that some agencies were unaware of the totality of the work they had been attempting with BD. Had they realised this and fitted all the pieces of the organisational jigsaw together their individual response to him would have been better managed and coordinated. Furthermore each organisation would have spotted more clearly the need to take responsibility to convene a wider examination of the partnership approach to this man.
It is of particular concern that the West Midlands Probation Service are unable to give a complete account of their statutory intervention in relation to BD.
Recommendation 2 – Management coordination and leadership
The Safeguarding Board should ensure all partnership agencies introduce policies that identify and analyse the reasons for high repeat usage by people of their services and that reports on the agency response to these occurrences are routinely reported to senior managers.
One of the key findings from some agency reports was that senior managers had been unaware of how often BD had accessed their services and how much time and resources he had been consuming. Without knowing something of those people who make high demands upon agency time and resources it is impossible to develop appropriate responses. Had senior managers known more about BD they would have been more likely to ensure staff responded to him more consistently and appropriately.
Recommendation 3 – Management coordination and leadership
Where there is multi agency acknowledgement that a person is vulnerable there needs to be joint agreement about lead responsibility overall and lead responsibility within each agency.
Even when there was multi-agency involvement with BD it was not clear who was taking overall responsibility for coordination of the total effort. Without this the focus of attention leadership appeared to move between Housing, Adult Social Care and Probation without any one service taking overall leadership and responsibility. Even within agencies it was not always clear who was taking overall leadership. For example, within Adult Social Care the Safeguarding Manager appeared to take the lead by default when arguably it ought to have rested with mental health
The Mental Health Trust should examine ways of ensuring that the Care Programme Approach is applied to ensure there is effective coordination of people accessing their day services, in-patient care and drugs and alcohol services
BD accessed three services provided by the mental health trust without there being any evidence that his total care was integrated and coordinated. As such opportunities for a more holistic approach driven by a clear multi disciplinary assessment were missed.
Recommendation 5 – Identifying someone as vulnerable
The Safeguarding Board should agree and implement minimum levels of training for partner agencies that ensure all front line staff are able to recognise who is or might be vulnerable and know how to respond appropriately to their needs.
Individual agency reports have highlighted clearly that their staff did not always recognise BD as a vulnerable person and therefore did not take action to address that vulnerability. It is important that agencies identify which of their staff need to be able to recognise if a person might be vulnerable and what action they should take to respond to this. Safeguarding Board members need to produce agency plans that ensure all staff who need to have this training are identified and a plan produced to ensure they have this within agreed timescales.
Recommendation 6 - Focus of intervention
The Safeguarding Board members should promote this report and in particular the importance of assessments that identify relevant predisposing issues that may lie behind specific requests for help.
BD was clearly a troubled man who presented substantial challenges to the many agencies who attempted to address the problems he presented. Everybody knew he had alcohol related problems that he was unwilling to address. Agencies tended to continue to respond to the symptoms reasonably well. Once they were less apparent the focus of concern tended to diminish. For example once the assaults and burglaries were addressed by a housing move, cries for help reduced and agency intervention diminished. However his underlying problems remained.
Although BD rejected the counselling and support offered through the Centre for Equality and Diversity this offer came at a relatively late stage. It is possible that with an earlier identification of his problems he might have been more amenable to accepting intervention to address the poor relationships he certainly had with his family. Possibly through that he might have also been encouraged to build stronger cultural and religious links.
Recommendation 7 –Focus of intervention
The frequent harassment and burglaries that BD was subject to in 2007-08 lacked a proper response. Even when he moved there were continued although less frequent incidents. This suggested his general conduct lifestyle, if not culture and race, led him to be singled out as a target of harassment and abuse. This was never identified as hate crime. Had it been so a more co-ordinated response might have been developed that not only ensured a more sustained focus on the perpetrators but also supported BD in avoiding some of the situations that brought him to the attention of those that tormented and harassed him.
