Safeguarding Adult Reviews

Martin's review in brief

Background

This Safeguarding Adult Review (SAR) was for Martin. Martin was a 49 year old White British man who died in February 2023.

Martin grew up in the North West of England and moved to Stockport in 2007 when he was 34. He had lived with his parents for most of his life. He was born with global learning difficulties, neuromuscular deficiency and developmental delay.

Martin struggled with living independently and before his death was known to Adult Social Care, Pennine Care NHS FT, Stockport NHS FT, Stockport Homes, and a private care provider.

Martin’s death in 2023

In October 2022 Martin saw his GP where a referral was made to Gastroenterology at Stockport NHS FT in relation to his liver disease. In December 2022 Martin attended A&E for swelling in his stomach. By January 2023 Martin’s carers raised concerns around an increase in his alcohol consumption, a decline in his mobility, and pain in his legs. Referrals were made to Pennine Care NHS FT, Stockport Homes Independent Living Team and substance misuse services. Martin was taken to Stepping Hill Hospital where he was admitted, and sadly died.

Learning disability support

Not all professionals working with Martin were aware of the full breadth of support available across Stockport for adults with learning disabilities. One of our areas of learning from the learning event was to help promote the full system of LD support in the borough, including in communities.

It wasn’t always clear that Martin fully understood information that was given to him, especially around his physical health needs and substance misuse. The view from family members was that Martin’s mental capacity had not been fully assessed around his alcohol consumption. Revisiting mental capacity assessments when working with adults with care and support needs gives an opportunity to re-visit risk and update any relevant assessments.

Where important information is given to adults with learning disabilities, professionals need to provide this in an accessible way and ensure the adult, their carer or advocate understand what is being communicated.

Responding to self-neglect concerns

Before Martin’s death, the local authority did not always respond to self-neglect concerns under Section 42 enquiries. Practice has now changed and all concerns for self-neglect will now be managed as a Section 42 safeguarding enquiry up to the point of an initial safety plan being implemented.

This ensures that multi-agency discussions take place to collect all relevant information and develop any initial safety plans with the right level of involvement of all professionals.

Professional confidence and escalating concerns

There were points in Martin’s life where professionals did not share information about their involvement, or escalate concerns for example where home visits could not be completed. Information sharing is one of the Safeguarding Partnerships’ strategic priorities. Read our business plan. It's important that care plans for adults are developed to address concerns in a coordinated way.

Where professionals have concerns that an individual requires additional support, or partner agencies could be working more closely together, these should be discussed with the relevant agency safeguarding lead or manager as appropriate.

Family networks

Martin’s family supported him through his time with services and seeking support for his alcohol addiction. The learning event heard rich feedback from Martin’s family and they were able to share lots of information about Martin to those professionals who were working with him. It is expected practice to understand the people that are important to an individual’s life, and who may be able to provide additional information on how to engage with them, or fill in any gaps.

What this means for me

To make sure that learning from this SAR is shared, make sure you've read the full review and consider the following:

• are you confident you know how to refer concerns around self-neglect?
• do you know when information needs to be shared with other professionals?
• are you confident in completing a mental capacity assessment?
• do you understand the safeguarding thresholds for referrals to the local authority?

Download and read the full review: