abnormal Inquiry

 

M ental I llness C oncerns A ll

 

 

 

 

 

M ental

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Social services; 'D'


Case Review

MT








This Serious Case Review has been carried out at the request of Newcastle Social Services by:-

 Davina Murton
Service Improvement Manager
Social Services Directorate
Sunderland City Council


For the purpose of the review the protocol used is that of Sunderland Multi-Agency Panel for the Protection of Vulnerable Adults. Appendix 1 of the report



CONTENTS OF REPORT

  1. Background and purpose of the review

  1. Identified Issues

  1. Recommendations
    Appendix 1 Case Review Protocol

    2         Contributors to the Review




    1. Background

    1. 1On 9th June 2005 at Newcastle Crown Court, MT pleaded guilty to the unlawful killing of OG.

      MT first become known to Newcastle Social Services Directorate in 1990 when she was referred by the Housing Department who were concerned about her living conditions. Her accommodation was a bed sit which was described as "dirty and infested with cockroaches." Cockroach infestation was not confined to MT's bedsit. MT had visual impairment and required surgery for cataracts. Whilst valuing her independence, she did agree to support.
      At that time, MT is described as being "very sad and lonely." It was inevitable therefore that she would develop a strong attachment to her Home Care Worker. MT's loneliness was addressed by encouraging her attendance at Benwell Day Centre.

      In 1991 MT was involved in an incident on the Day Centre transport when she struck a fellow service user. Upon investigation it transpired that MT shared the same Home Support Worker with the service user. The motivation for the incident was considered to be that of jealousy. The records do not show how that incident was addressed other than her attendance at the Day Centre was cancelled.

      At the same time and at her own request, MT discontinued home support and meals at home.

      On 17th August 1994 MT once more came to the attention of the Social Services Department when the police referred her following an assault by MT on an elderly neighbour. She had hit a neighbour over the head with a chair leg. The assault was serious and required the victim to be admitted to a neurological ward for treatment. Social Services records show that there had been longstanding disagreement between the two.
      The Police opposed MT being bailed to her home address. The decision making process to place MT in Residential Care is obscure. Social Services records show that this was done at the request of the Police however the Police have no record of this.

      At the time of the arrest the Police would have known through the Police National Computer of MT's history and in particular the occasion of her being committed to Rampton. There is no record in the social service files that this information was shared with them. It is unknown if the Probation Service were involved since the records have been destroyed in accordance with their criteria.


      A Social Work assessment was carried out and the care plan indicated that MT required provision of accommodation, assessment of her mental health and assistance in managing finances. She was admitted to Chirton House Local Authority residential Home. There is no evidence that a specific risk assessment had been carried out into MT's propensity for violence. However a referral was made for a Psychiatric assessment on 6th September 1994.

      MT was seen by a senior consultant in Old Age Psychiatry on 14th September 1994. No evidence of mental disorder was apparent and an EEG was reported as normal. Whilst the psychiatric report shows that MT had an admission to St Luke's Psychiatric Hospital in her twenties there is no information as to the cause of admission or indeed any other detail.

      MT was made the subject of a 2 year Community Rehabilitation Order on 16th February 1995 for an indictable offence. The Order was discharged by the Court on 5th July 1996 in recognition of the good progress made by MT. There are no records available from that time. The individual case records were destroyed in accordance with the Probation Service Policy in October 2002. The policy states that "records must be destroyed five years after the last statutory contact unless the offence/offender falls into an exemption category, for example, life sentence prisoners."

      In 1996 social work records show that MT wished to return to live in the Community and an attempt was made to secure sheltered accommodation. This proved unsuccessful.

      In March 1996 MT moved to Cestria House (Independent Residential Care Home). Reviews held showed that MT had settled well. There is no evidence that the home had been informed of MT's violent history and there is no reference to her criminal record in the review documents. Active oversight by the Social Services Department ceased and the case was placed in the system for carrying out regular reviews.

    1. 12Between March 1996 and February 1998 all appeared to be well. MT was moved for one month from Cestria House to Cestria Lodge following a flood.

      In March 1999 the Social Services department became actively involved when MT requested a move to Guisborough where she is believed to have originated. She was also provided with information on other homes in Newcastle. In June 1999 she briefly moved to Ella McCambridge House but chose to return. In July 1999 she moved to The White House in Jesmond along with twelve other residents when Cestria House closed.

      In June 2000 a referral was made to the Social Services Department when MT had allegedly hit one resident on the hand and another with her handbag. Both of these residents had challenging behaviours. The situation was reviewed and discussed with the Joint Inspection Unit. There were no Adult Protection Procedures in place at this time. An Agreement was made to monitor the situation. A further review in July 2000 shows that there had been no further incidents and plan to give MT additional staff support was working well. A review in six months was agreed.

      Due to data entry errors the review did not take place after six months. However this error came to light in July 2001. There were no issues in relation to MT at that time. MT continued to be reviewed regularly and there were no concerns expressed at any of these. The last review in January 2004, one month prior to the assault on OG records show that there were no concerns about MT's health or her placement. She was able to go out of the home on her own as she wished.

      On 1st February 2004 all appeared to be well until later in the evening MT was seen by staff to be walking around the home because she could not sleep. The care staff noted that she had three skin breaks on her arm which MT said that she had inflicted them upon herself.
      The following day the matter was reported to the GP and all sharp objects were removed from MT's room as a precaution. Staff observed MT at 30 minute intervals.
      At 2-00pm that day, MT was found to have broken a table lamp and was once more attempting to use the broken pieces to self harm. Contact was made with the hospital and a duty nurse arrived at 3-45pm to dress MT 's wounds.

      MT was seen at length by the GP who prescribed Diazepam. The Home Manager suggested a psychiatric assessment but the GP felt that was unnecessary.

      Until the 5th February MT continued to be restless and was not sleeping too well. Her wounds were dressed regularly by the District Nurse. Antibiotics treated the infection in her wound and there had been a change from Diazepam to Tamazepam. By 6th February MT's appetite had improved and she was described as brighter.

      At approximately 2-57am on 7th of February, MT was found in OG's bedroom. OG was lying across her bed and both she and MT were heavily blood stained.

      Management reports demonstrate that no single agency had a comprehensive background history of MT. Much of her earlier life still remains unknown, yet from early childhood, she had a string of significant life events.

      It has now emerged from health records that she was born in Middlesbrough It is understood that that MT missed a year at school when she was 13 years old. Records show that she was diagnosed as having St Vitus Dance, also known as Sydenham Chorea.
      She was placed on Probation for theft from the purse of a blind woman.
      Following the death of her father in 1950 She had taken an axe to smash her neighbour's furniture. MT appeared in Guisborough Magistrates Court on 13th February, 1951 and was convicted of malicious damage.

      She was given a Hospital order and committed to Rampton Prison Hospital. It is recorded that MT remained in Rampton for the next 17 years.


      From then on MT was in an out of psychiatric hospitals. From 1951 until 1966 she spent prolonged periods in Rampton, Tillworth Grange, Mosside (now Ashworth), Ayecliffe, and St Nicholas.

      Detailed records are no longer available but it would seem that at least some of these admissions were the result of violent behaviour.
      Certainly, records do show that she was admitted to Tillworth Grange in 1953 where she demonstrated violent tendencies. She attacked fellow patients and repeatedly absconded.
      It would appear that there are no records from 1964 till 1994.

      GP records are not available before 1970.


    1. 24MT also has three convictions for shoplifting in Newcastle. The first was on 7th December, 1975 when a 2 Year Probation Order was imposed. The second was on 19th December 1979 and resulted in a conditional discharge. The third was on 14th April 1980 which resulted in a 1 year Probation Order. Throughout this time MT was living alone and was unemployed.

      Apart from a minor incident in June 2000, from August 1994 until February 2004, MT had lived in residential care without incident. In spite of having made four moves in four years MT had coped exceedingly well. She enjoyed a good quality of life, which included daily trips into the community. No management issues are reported by either the Social Workers or Home Manager.

      st February to 6th was rapid. Her symptoms were managed and treatment was sought appropriately . Although MT was not sleeping well and she was entering on a path of self-harm, staff had done all that was reasonably possible to help her. The medical records available indicate that self-harming was a new phenomenon for MT Daily visits were made by the District Nursing Service from the 3rd and 6th of February. They report her as being, "quiet, calm and co-operative." Given that harm was being directed towards herself, although worrying, there is absolutely nothing to suggest anyone could have predicted the tragic event that was to take place that evening.



      Identified Issues
        It is clear that no single agency was in full possession of the facts surrounding MT's background and psychiatric history. Records were either, not kept, lost or destroyed in accordance with the criteria of the relevant agency.
        Records that were available do not give a detailed account of what led up to incidents occurring and what the decision-making processes were for investigation and decision-making.

      Following the assault of August 1974 the Police would have known from the Police National Computer of MT' convictions and in particular her being committed to Rampton. If the Police shared this information with the social services department it is not recorded in the file. Certainly staff interviewed do not recall having been told of MT's convictions. They are sure that such significant events would have been recorded. Equally the Police believe that they would have passed on this type of information
        It is not clear that information provided to Chirton House upon MT's admission in 1994, were subsequently passed on to other homes as she moved on. Indeed Coniscliffe Care Centre did not have information regarding MT's criminal convictions or her psychiatric background.

      The Department of Health, National Minimum Standards requires that "New service users are admitted only on the basis of a assessment undertaken by people trained to do so and to which prospective service users, his/her representatives, (if any) and relevant professionals have been party". 1 National Minimum Standards for Care Homes For older People 3.1

      In this case the Social Services Department had carried out the assessment in good faith and formed a care plan in accordance with the information that was available to them. Even with the knowledge of MT's previous convictions for theft and criminal damage, they may well have still made the placement. However, they would certainly have wanted to put measures in place to monitor the situation closely, as would the Residential Home itself.

      Since the Probation Service records have been destroyed it is not possible to say if they had knowledge of MT's previous convictions. In any event the Social Services records do not show that any such information was given to them.

      It is clear that the Consultant, who provided a psychiatric report in 1994, did not have at the time a full medical history. Certainly the correspondence does not give any indication of the background beyond the period of time spent at St Luke's Hospital. The reason for admission is also not stated.

      In 1994 when MT assaulted her neighbour, strategies for inter agency working did not exist in the way that it does today. Whilst social worker staff would always endeavour to gather as much information as possible to inform their judgments, there were no protocols to support them.


      Recommendations

    It is clear from the management reports that each organisation will have learned from this process and have issues that they wish to address at a local level. The recommendations being made here are aimed at the Strategic Partnership level.

     Recommendation 1

     "All persons have the right to lives free from violence and abuse. The right is underpinned by the duty on public agencies under the Human Rights Act (1998) to intervene proportionately to protect the rights of citizens. These rights include Article 2: 'the Right to life'; Article 3: 'Freedom from torture' (including humiliating and degrading treatment); and Article 8: 'Right to 'family life' (one that sustains the individual)." Draft National Standards for 'Safeguarding Adults' 2005 Standard 1

     It is essential that all Agencies co-operate in further developing Multi Agency Adult Protection Policies and Procedures.

    Recommendation 2

    "Safeguarding Adults Partnership" should be given a high priority by Senior Managers in all organisations and should be funded appropriately.


    Recommendation 3

    All staff should be appropriately trained in Adult Protection Policies and Procedures and be confident about lines of accountability.


    Recommendation 4

    The training of staff in Adult Protection should be done in a multi-agency way in order to build good professional relationships, together with shared understand of what constitutes abuse and good practice.


    Recommendation 5
    Whenever there is tragic event, one of the issues, which commonly arise, is information sharing, or the lack of it. The Bichard Inquiry into the deaths of Jessica Chapman and Holly Wells, is perhaps the most recent notable example.

    All Agencies should agree an information sharing protocol that will encompass all principles of information sharing and address issues of confidentiality.



    Recommendation 6

    All Agencies should monitor the accuracy and comprehensiveness of their record keeping, both physical and electronic.

    Recommendation 7

    All Agencies should review their policies in respect of retention and destruction of case files.

    Recommendation 8

    All Agencies involved in care assessment and provision should ensure that they hold a comprehensive Social Care Report. Any gaps in the history relating to, criminal behaviour, Mental Health issues, any risk factors, should be identified and addressed.


      Appendix 1

      Case Reviews The Protection of Vulnerable Adults

      Introduction

      When a vulnerable adult dies, and abuse or neglect are known or suspected in the death, local agencies should consider immediately whether there are other vulnerable adults at risk of harm who may need protection. Thereafter, agencies should consider whether there are any lessons to be learned from the tragedy about the ways in which they work together to protect vulnerable adults. Consequently, when a vulnerable adult dies in such circumstances, MAPPVA should always conduct a review into the involvement of agencies and professionals with the victim and his/her family. Additionally, MAPPVA should also consider whether a review should be conducted where a vulnerable adult sustains a potentially life-threatening injury or serious or permanent damage to their health or physical well-being.

      The Purpose of Reviews

      The purpose of case reviews is to:

      1. ·Establish whether there are lessons to be learned from the case about the way in which local agencies and professionals work to together to protect vulnerable adults from abuse
      2. ·Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result or consequence, and
      3. ·Contribute to improving multi-agency working in the protection of vulnerable adults by reviewing and ensuring the appropriate use of policy and procedures


      Case reviews are not enquiries into how a vulnerable adult has died or who is culpable; that is a matter for Coroners and Criminal Courts respectively to determine, as appropriate.


      Who Should Conduct Reviews?

      The initial scoping of the review will be conducted by the MAPPVA Coordinator and should identify those who should contribute, although it may emerge, as information becomes available, that the involvement of others would be useful. In particular, information may become available through criminal proceedings, which may be of relevance to the review.

      Each relevant service or agency should undertake a separate management review of its involvement with the vulnerable adult. This should begin as soon as a decision is taken to proceed with a review

      MAPPVA should commission an overview report which brings together and analyses the findings of the various reports from agencies and others, and which makes recommendations for future action

      Those conducting management reviews of individual services, or producing the overview report, should not have been directly concerned with the vulnerable adult or his/her family


      Management Reviews

      The aim of management reviews should be to look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made, and if so, to identify how those changes will be brought about

      Management review reports should be accepted by the MAPPVA Coordinator, who will be responsible for ensuring that recommendations are acted upon

      The following outline format should guide the preparation of management reviews, to help ensure that the relevant questions are addressed, and to provide information to MAPPVA in a consistent format to help with preparing an overview report. The questions posed do not comprise a comprehensive check-list relevant to all situations. Each individual case may give rise to specific questions or issues, which need to be explored. Each review should consider the circumstances of individual cases and how best to structure a review in the light of those circumstances. Where staff or others are interviewed by those preparing management reviews, a written record of such interviews should be made and this should be shared with the relevant interviewee.


      MANAGEMENT REVIEWS


      What Was Our Involvement with the Vulnerable Adult?

      Construct a comprehensive chronology of involvement by the agency/service and/or professional(s) in contact with the vulnerable adult over the period of time set out in the review's term of reference. Briefly summarise decisions reached, the services offered and/or provided to the vulnerable adult, and any other action taken


      Analysis of Involvement
       Consider the events that occurred, the decisions made, and the actions taken, or not. Where judgements were made, or actions taken, which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why it happened. Consider specifically:

      1. ·practitioners or staff sensitive to the needs of the individuals using their service? Were they knowledgeable about potential indicators of abuse? Did they know what to do if they had concerns about a vulnerable adult?
      2. ·the agency/organisation/service have MAPPVA Policy and Procedures in place? Were all staff aware of this and understand how to use procedures?
      3. ·a MAPPVA alert made in relation to concerns about the individual? If so, what followed from the alert? If not, why not?
      4. ·were the key relevant points for assessment and decision making in this case, in relation to the vulnerable adult? Do assessments and decisions appear to have been reached in an informed and professional way?
      5. ·actions accord with assessments and decisions made? Were appropriate services and/or information offered/provided, or relevant enquiries made, in the light of assessments?
      6. ·Where relevant, were appropriate care plans, risk management plans or risk assessments in place and reviewed on an agreed, regular basis?
      7. ·When, and in what way, was the vulnerable adult's wishes and feelings ascertained and considered? Was this information recorded?
      8. ·practice sensitive to the racial, cultural, linguistic and religious identity of the vulnerable adult?
      9. ·more senior managers, or other agencies and professionals, involved at points where they should have been?
      10. ·the work in this case consistent with MAPPVA policy and procedures in the protection of vulnerable adults?

      What Do We Learn From This Case?

      Are there lessons from this case for the way in which this agency/service/organisation works to protect vulnerable adults? Is there good practice to highlight, as well as ways in which practice can be improved? Are there implications for ways of working; training (single and multi-agency); management and supervision; working in partnership with other agencies; resources? Are there implications for MAPPVA policy and procedures?
      Recommendations for Action

      What action should be taken, by whom, and by when? What outcomes should these actions bring about, and how will the agency review whether they have been achieved? Do recommendations need to be made to the MAPPVA panel in relation to policy and procedures?



      Upon completion of the review report, there should be a process for feedback and de-briefing for staff involved, in advance of completion of the overview report by the Mappva Coordinator. There may also be a need for a follow-up feedback session if the overview report raises new issues for the agency and staff members

      Management reviews are not part of any disciplinary process, but information that emerges in the course of reviews (either management or overview) may indicate that disciplinary action should be taken under established procedures. Additionally, reviews may be conducted concurrently with disciplinary action. In some cases, disciplinary action may be urgently needed to protect other vulnerable adults who may be at risk.

      2. MAPPVA Overview Report
      3. MAPPVA overview report should bring together and relate the information and analysis contained in the individual management reviews, together with reports commissioned from any other relevant interests.
      4. MAPPVA Coordinator will:

      6. ·Ensure that contributing agencies and individuals are satisfied that their information is fully and fairly represented in the overview report
      7. ·Translate recommendations into an action plan, which should be endorsed and adopted at a senior level by each of the agencies involved. The plan should set out who will do what, by when and with what intended outcome. The plan should set out how improvements in practice/systems will be monitored and reviewed
      8. ·Clarify to whom the report, or any part of it, should be made available
      9. ·Disseminate report or key findings to interests as agreed. Make arrangements to provide or arrange feedback and de-briefing to staff, family members, and media, as appropriate


      12. Reviewing Institutional Abuse
      13. serious abuse takes place in an institution, or multiple abusers are involved, the same principles of review should apply. However, they are likely to be more complex, on a larger scale, and may require more time. Terms of reference need to be carefully constructed to explore the issues relevant to the specific case. For example, if individuals had been abused within a residential establishment, it would be important to explore whether, and how, the establishment had taken steps to create a safe environment for its residents, and to respond to specific concerns raised.


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