Safeguarding Adults Review: Alison
Alison was in her late fifties and lived with her civil partner. Alison had a long history of substance misuse and continued to use heroin up until the time of her death. Her drug use was considered as a significant contributory factor in her multiple health issues.
Alison was reliant on her partner, a wheelchair user, and carers to support her, and struggled to mobilise from her bed. Alison also smoked around twenty cigarettes a day.
There were a number of agencies who had regular contact with Alison, including the care agency and district nurses. Alison’s partner Debbie also had a package of care in response to her own health issues.
Others struggled to maintain engagement with Alison, who would decline offers of support. A Safeguarding Adults Review was commissioned following Alison’s accidental death in December 2021 as a result of a fire in her own home.
This review sought to understand how professionals are able to balance risk with a person’s right to choice and autonomy, particularly in those cases where a person refuses support.
Multi-agency communication is key to managing the risks for any case.
We as professionals must ensure that we are being proactive in sharing what we know with relevant agencies. Different practitioners often receive different information, and sharing these perspectives allows us to see the full picture. Having an awareness of what other partners can provide to mitigate risks also helps us to plan and share the risk.
Whilst Alison was deemed to have capacity to make decisions in relation to her care and support needs, the review has led to reflection on how we understand fluctuating capacity and executive functioning. This is particularly pertinent when a person is known to be living with addiction.
This review has highlighted gaps in our understanding of fire risk. This includes suitable training provision and ensuring that we have robust risk assessments, which the SAB is considering as part of its action plan.
As practitioners we also need to consider what we can do to mitigate risk, including consideration of use of available technology.
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7-mintute briefing on Alison (PDF, 187.12KB)
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Video: Learnings from the SAR for the Alison
What is a 7-minute briefing?
7-minute briefings are a learning tool developed to help us focus on the key issues around a particular theme, current issue or from a learning review (such as a Safeguarding Adults Review).
How can I use this tool?
Discuss the briefing in a team meeting and reflect on how this could influence your approach to future cases.
Consider having this as a standing agenda item.
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Schedule time to look through the links to further information to expand your knowledge on the subject.
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What next?
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Taking note of your reflections and action points will also allow you to reflect on the learning at a future supervision or team meeting to see how practice has changed or if there have been any positive changes.