Safeguarding Adults Review: Brian
Brian was a 50-year-old army veteran who experienced adverse physical and mental health issues, and substance misuse.
He had also experienced homelessness and had spent time in and out of prison. He was known to a wide range of agencies who had varying levels of interactions with him. Some agencies had a good relationship with Brian and worked hard to find ways in which to support him. At times, working with Brian could be a challenge.
In February 2022 Brian attended hospital following a physical assault, he received a head scan and was discharged home. Five days later, following concerns raised by his tuberculosis nurse, police attended Brian’s property and found him deceased.
Consequently, a Safeguarding Adults Review was commissioned to consider the ways in which partner agencies worked together to support Brian.
Brian’s needs were complex and his behaviour could be complex. The review recognised the impact on workers, many of whom demonstrated good practice. The SAB is now reviewing the support made available to staff.
Multi-agency working is key to effective safeguarding work. In Brian’s case there were many professionals all working hard to support Brian, but the review has highlighted the importance of work in a joint and coordinated way, with a lead person who has oversight of a case.
Key to this is consideration of when to escalate concerns to senior managers, or where necessary, multi-agency panels (such as the high-risk panel).
The review explored mental capacity in relation to adults like Brian who use drugs and alcohol, and the impact this may have on executive functioning or fluctuating capacity.
At times Brian could also be seen to be making what appeared to be unwise decisions. The review prompts us to consider how perceptions of a person’s capacity may change when repeated unwise decisions are looked at in the longer view. In all cases, we must ensure we have clear recordings of determinations of mental capacity.
A person’s lived experience can impact on access to services, engagement and service responses. The review has made recommendations on trauma-informed approaches and awareness of intersectional approaches, so that we can reflect on our assumptions and supports our assessments, review of risk and care planning.
What is a 7-minute brieing?
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.
Use the briefing in supervision - Can a review of briefings help identify useful links to practice?
Schedule time to look through the links to further information to expand your knowledge on the subject.
Can you incorporate the briefing into relevant training offers or share on your organisation's website or intranet?
What next?
If you have used this briefing, please take time to complete our lessons learned template.
This will help us gather feedback on how useful the briefings are to those using them, and how the learning has enhanced their practice.
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.