Case study: Frank
In July 2023, the Safeguarding Adults Case Review Group reviewed information relating to a fire fatality in the borough to determine whether this met the criteria for a Safeguarding Adults Review (SAR - Section 44). This involved a gentleman who we have referred to as ‘Frank’.
Frank was a 71-year-old white British man who lived alone in a 1-bed council flat and had a care package in place at the time of his death to assist with personal care and prompts with medication, in addition to weekly visits to support with housework and food shopping. Frank had several physical health conditions, including Type 2 diabetes.
District nurses would visit twice daily to support compliance with insulin medication and wound management. Frank also lived with depression and had a historic involvement of mental health services, as well as a history of substance misuse from his youth.
Sadly, Frank passed away in September 2022 due to burns from an accidental fire in his bedroom caused by smoking material. At the time, he was likely unconscious, which the coroner determined was likely due to an episode of hypoglycaemia.
The risk of a fire in Frank’s home appeared to escalate in the period shortly before his death, possibly linked to his relapse into heroin use. Two days before the fire, the care agency reported an incident where Frank had left the gas cooker on before going to bed. Then, on the day of fire, the carer reported to police that Frank had been less alert during his earlier afternoon visit. During this visit, the carer had noticed a small fire was starting in the ashtray on the living room floor which the carer put out.
On review of this case, the Safeguarding Adults Case Review Group determined that there were no immediate concerns around the way agencies worked together, and so the case did not meet criteria for a statutory SAR. Instead, it was agreed that a piece of work should be undertaken to identify similarities with SAR Alison (concluded April 2023) and capture any new areas of learning.
A review of the information provided by partner agencies was undertaken by the H&F Safeguarding Adults Board Manager, which primarily considered events between September 2021 and Frank’s death in September 2022.
Key areas of learning
There was a lack of evidence or clear recording of assessment of mental capacity, as highlighted previously in SAR Alison. A number of SARs completed elsewhere across London and nationally point to the need for assessment under the under the Mental Capacity Act to be seen as a much more routine step in practice where an individual is placing themselves at high risk of serious injury or possible death.
Like Alison, Frank was also known to be using heroin in the period shortly before his death, with other reports in July 2022 referring to Frank drinking heavily. This may have impacted Frank’s decision making, with him potentially having fluctuating mental capacity under the influence of drugs. This may have impacted his ability to understand risks associated with both medication compliance and fire safety.
Another feature that reflects the learning from elsewhere is a person’s right to make what are deemed as ‘unwise decisions’. This can create difficult situations for professionals who may be unsure of how to respond when someone is refusing the essential support they need, and they are deemed as having capacity to make that decision. Other London SARs have pointed out that whether a person is capacitated or not regarding a specific decision should not be the end of the assessment or closure of any risk assessment processes
Research around best practice in working with individuals who self-neglect outlines the need to complete thorough assessments of care and support needs and undertake comprehensive risk assessment. Previous analysis of SARs in London has also noted examples of practitioners giving insufficient attention to, or having lack of understanding, of a person’s history and possible reasons for their self-neglect, and this was reflected in the interactions with Frank.
Whilst the carer was able to extinguish the fire in Frank’s ash-tray themselves, best practice would have been to call the London Fire Brigade (LFB) at this point as LFB will still attend these incidents. Whilst we cannot say whether this would have prevented the subsequent events of that day, in similar situations the LFB can help to ensure that all potential risks for future fires have been identified with risks mitigated.
Areas of good practice
Frank’s case also highlighted examples of good safeguarding practice, such as the response of the Frailty Multi-Disciplinary Team shortly before his death in September 2022. This multi-agency forum was used as a vehicle to raise concerns about Frank’s heroin misuse, hypoglycaemia, and self-neglect.
Due to the level of concern, it was agreed that a joint home visit would be carried out by the GP, district nurse and consultant geriatrician to undertake a mental capacity assessment. Unfortunately, this was unable to take place due to Frank not being home when professionals attempted this home visit only a few days before his death but demonstrates proactive response to risk and action planning.
There were also examples in the chronology of proactive steps made to address fire safety in the home. On more than one occasion, health professionals from Imperial College Healthcare NHS Trust had offered smoking cessation services to Frank, which Frank refused. Adult Social Care also conducted a person-centred fire risk assessment in March 2022, which led to a recommendation for smoke alarms to be installed with links to Carelink.
Records also provide evidence of professionals having direct conversations about risks with Frank, and examples of seeking to provide practical solutions to support Frank’s medication compliance, such as placing all medications in blister packs.
Podiatry services (Central London Community Healthcare NHS Trust) also responded to repeat missed appointments (which Frank put down to ‘a sign of old age’) by placing on Frank on the vulnerable reminder call list.