7 minute briefing - J

Background

WLNHST carried out a serious incident (SI) examining the death of a 67-year-old man. Ealing SAB carried out a multi-agency learning event once the SI was concluded. The gentleman lived in supported accommodation in a warden assisted flat in Ealing, he had suffered a stroke in 2018 and had significant healthcare needs with concerns raised about his functional levels. At the time of his death, arrangements were being made for him to move to a higher support accommodation. There was a dual diagnosis of delusional order, recurrent depressive disorder and harmful use of alcohol. He was found deceased beside the River Brent, Brent Park Lodge, Hanwell June 2020. The cause of death was drowning and use of the Venlafaxine, Mirtazapine, zopiclone, ischaemic heart disease and mitral valve disease. He was known to wander with increased confusion and he had been fitted with a Careline tracking device in early June of 2020.

Safeguarding concerns

  • Change in presentation in weeks prior to death – increased confusion.
  • Consideration of raising an Adult Safeguarding Concern in early April when strangers reported to have been in the flat.
  • Discharge planning arrangements following both admissions from Ealing Acute Hospital. Impact of COVID 19 pandemic, influence on risk assessment and care planning.
  • Referral to Psych Liaison for advice only by North 6 on 29 May, ‘’no concerns regarding mental health’’.
  • On discharge fitted with tracking device and enhanced package of care for 6 weeks. Lack of response on the day of incident.
  • Understanding the medication history of those with complex health needs and the role of primary care under safeguarding concerns.

Key lines of enquiry

  • Independence: It was noted during discussion that the client wanted to maintain dependence.
  • The impact of COVID: Deterioration occurred during the first national COVID lockdown.
  • The importance of understanding full history: Holistic planning for care.
  • Planning and effective discharge: From Acute Hospital involving those involved in client’s care.
  • The importance of strong information sharing: Between professionals to have an up to date understanding of the situation.
  • Professional curiosity: Capacity and communication skill to understand the lived experience of an individual.

Findings

  • Remind professionals of the importance of  sharing information to support strong and effective planning.
  • For staff to make the link between responding to Merlin reports and recording safeguarding concerns on RiO database
  • The critical role of GP’s and primary care in the community, especially for those who may need support managing medication.
  • Ensure discharge planning shares the discharge summary, with aspects of physical and mental health for complex individuals being addressed.
  • The reconfiguration of community services within WLNHS trust is an opportunity to share an up-to-date directory of services and who’s who.
  • Consideration needs to be given to determining the exact needs of someone who may be prone to wandering. Is a GPS tracker needed – as this relies on an individual taking it with them and may not provide the necessary assurance, OR an exit alarm which simply advises on entry and exit to a property. Information should be circulated to professionals to support the decision making.
  • The GPS Tracker has limitations, as the user would need to have it on their person all the time.

Practice implications

  • It is Important to understand the benefits and limitations of tracker devices. 
  • It is important that for those with significant medication regimes that the role of primary care in monitoring continues.
  • The role of effective planning on a multi- agency basis is important to develop clear and concise plans
  • Information sharing is crucial and should include family and friends.

Implementing change

Reflect on the findings with your team or service and discuss how this might impact on your practice. Identify what you or your team might do to act on the findings and to implement any change. 

Resources and further information