7 minute briefing - Piotr

Background

Piotr was a 56-year-old white Polish man. On 1st April 2023, he was found lying on the floor of his flat by a neighbour and was taken to Ealing Hospital. On admission, he was found to be in an unkempt and malnourished state with multiple pressure sores. On 7th April, he had a cardiac arrest. He died in mid-May 2023 without leaving Hospital. He had a background history of excessive alcohol use, self-neglect, mobility issues, and poor nutrition. Piotr spoke very little English, and a Polish translator was needed to facilitate communication with him.

Safeguarding concerns

A referral for a safeguarding adult review (SAR) was submitted by Ealing Social Services Safeguarding Adults Team as a result of concerns about the lack of joint working and professional curiosity. Piotr did engage with agencies but appeared incapable of looking after himself and declined the package of care on.

Key lines of inquiry

All agencies involved with Piotr’s care contributed to the Review, attending a learning event in March 2024 

  • Ealing Adult Social Care
  • GP
  • Health Trusts
  • Police
  • Ealing ASC reablement team/ Independent living services
  • Depaul UK – West London Floating Support Service

Findings

Ealing has a good array of alcohol services; nonetheless, opportunities to support Piotr in the management of his alcohol use disorder appear to have been missed. He was referred to RISE in November 2022 by his support worker but there is no evidence that he engaged.

Nothing in the notes is critical of the response from Alcohol and Drug Services. However, Piotr could have benefited from an assertive outreach approach which would have attempted to build a relationship with him in order to understand what lay behind his complex pattern of behaviour, reduce harm and motivate him towards engagement with treatment.

The ideal care pathway for Piotr would probably have been inpatient detoxification followed by a period of residential care / rehabilitation in a “dry environment.” This would have enabled: 

  • a time away from the home situation in a protective environment
  • a chance to properly assess him, including any possible cognitive impairment
  • the opportunity to address the substance use disorders and develop an appropriate long-term care plan

It was suggested that agencies may not have raised concerns because they assumed that others would be doing that or assumed that a referral to Adult Social Care would then automatically trigger a Section 42 referral This does seem to suggest potential learning from this case about the need to: 

  • submit safeguarding concerns about people like Piotr 
  • understand the difference between a Section 42 referral, a section 9 referral and a request for support 
  • use professional curiosity to look behind claims by a client that they are able to care for themselves

Practice implications 

  1. Ealing’s Public Health Team should ensure that all frontline services are aware of, and are able to use, robust alcohol screening tools such as the AUDIT tool to identify and record the level of alcohol related risk for clients.
  2. Public Health Commissioners who commission and plan the development of alcohol and drug treatment services should review whether the specific needs and impacts of chronic, dependent drinkers that services find difficult to engage are identified in needs assessments and addressed in any future commissioning plans. In particular, investment in assertive outreach capacity for this group of clients should be considered locally. Particular, investment in assertive outreach capacity for this group of clients should be considered locally.
  3. Ongoing training about:
    • the need to recognise that people with alcohol use disorders may be self-neglecting and the importance, therefore, of raising safeguarding and Care Act section 9 referrals
    • the importance of not making assumptions about other agencies taking on that role
    • the difference between these types of referrals to Adult Social Care
    • the importance of professional curiosity in understanding what lies behind a presentation

Good practice

Although there are questions about aspects of Piotr’s care, specific points of good practice did emerge: 

  • the persistent outreach and advocacy work undertaken by the Depaul charity floating support worker. Piotr appears to have consistently engaged with this service, accepting all the help offered
  • this service also made many referrals to other services and repeatedly reached out to try to obtain help and support for Piotr
  • the GP used the AUDIT tool with Piotr on at least one occasion

Implementing change

Reflect on the practice implications with your team or service and discuss how they can be implemented. Identify what you or your team might do to make changes or whether training is required.

Resources and further information