1. Background
A female resident of a Care Centre funded by the CCG in the London borough of Ealing since 2018 was awaiting an assessment to determine appropriate placement. She was diagnosed with type 1 diabetes in 1962, came into contact with mental health services in 2014 and was diagnosed with Paranoid Schizophrenia. She was open to the H&F Treatment and Recovery Team, CPA, and Care Coordinator. She died in the Care Centre on 30 September 2020; the cause of death was Diabetic Ketoacidosis. This was following several previous admissions to the hospital from the Care Centre with Diabetic Keto acidosis.
2. The Legal Framework
The Care Act (2014) statutory guidance - Adult Safeguarding Concern Raised 08/2022: Neglect – not progressed until the resident died/
Article 2 of the Human Rights Act 1998 - An absolute right to life.
Mental Capacity Act (2005) – Lasting Power of Attorney (LPA): LPA allows the attorney to make decisions about the donor’s health and care. It covers daily decisions like food and drink, clothing and activities, and more significant decisions such as where to live and receive medical treatment. It can only be used when the donor has lost the mental capacity to make the relevant decision for themselves. The brother held LPA for health welfare and finances. However, some of the organisations involved in her care were unaware of the LPA and did not liaise with the brother.
3. Type 1 Diabetes
Type 1 diabetes causes the blood glucose (sugar) level to become too high. It happens when the body cannot produce enough insulin, a hormone that controls blood glucose. Insulin is to be taken daily to control blood glucose levels.
The resident’s diabetes management was unstable, and she required specialist intervention.
4. Paranoid Schizophrenia
Schizophrenia is a severe long-term mental health condition. It causes a range of different psychological symptoms, which affect thinking and the ability to cope with day-to-day life. For example, she believed her food was being poisoned which led her to stop eating. This made her diabetes management particularly difficult.
5. What to consider?
Balancing autonomy and protection is essential, and assessing mental capacity is crucial. A person with the capacity has the right to make decisions even if they threaten their health or safety. Her brother held LPA; therefore, he would be responsible for making decisions on the resident’s behalf.
6. Safeguarding
Safeguarding duties apply where the adult has care and support needs, is at risk of abuse or neglect, and cannot protect themselves because of their care and support needs. In most cases, the intervention should seek to minimise the risk while respecting the individual's choices.
Neglect is a category under adult safeguarding in The Care Act (2014) Statutory Guidance. This requires local authorities to make enquiries, or cause others to do so, if it believes an adult is experiencing, or at risk of, abuse or neglect. The London Ambulance Service raised concern following the omission of insulin and vomit on the resident’s clothing and bed when she was conveyed from the Care Centre to a hospital.
7. Recommendations of the review
- Processes should be in place to support duty workers to escalate safeguarding concerns to the local authority.
- Guidance concerning completing yearly physical health assessments for patients on CPA with psychosis diagnosis.
- Face-to-face contact with patients when there are concerns about the welfare or contingency plans.
- Discussion between the responsible care team and the local authority when safeguarding concerns are raised.
- Diabetes service must review their referral process to confirm follow-up of service users.
- Review of the physical health pathways in the community and ensure staff are competent in raising concerns.