Independent investigation: Jenny Bryant, Consett

This incident has highlighted a situation where vulnerable adult risk was assessed only in relation to the victim, and perpetrator risk was not considered. It is accepted that the safeguarding framework and guidance is victim focused; however, it is also noted that neither the framework nor the guidance was developed with ‘vulnerable adult on vulnerable adult’ incidents in mind. Therefore, the local authority is encouraged to review the design of its risk threshold tool and the documentation tools it provides to its staff to record their risk considerations, so that the tools themselves support the documentation of a structured assessment of risk across all of the domains set out in the threshold tool, and the consideration of risk in relation to situations in which both perpetrator and victim are vulnerable adults. To achieve this, the independent author suggests consideration of: • The narrative space in the current risk threshold: this could be more structured. An enhanced structure could drive active consideration of perpetrator risk where the perpetrator is also in receipt of care and is him or herself a vulnerable adult. • A risk assessment process that is designed to include specific questions. Examples are:  What harm was caused by this incident to the victim?  What were the circumstances of the incident in terms of: - location of incident and ‘line of sight’ for care home staff - how the incident was discovered (for example by chance, or because of planned activities)? In addition: The independent author recognises that the local authority has made considerable investment in risk management and risk assessment training for its staff. However, the independent author encourages the local authority to ensure that sufficient emphasis is placed on the basic elements of how to conduct a structured risk assessment (that is, considering what has happened in terms of outcome, what could happen if this recurred tomorrow and what is the reasonable likelihood of this happening again) alongside the complex range of issues professionals within social care and related agencies are required to consider.

This case highlights the importance of having a clear and structured risk assessment and management process within a care home environment. MR’s care home had an incident reporting system in place, as well as a process for reviewing reported incidents. However, the assessment of risk potential and how this was to be reduced was not documented on Datix as part of this process, and neither was there a requirement to do so. Registered care home managers recorded the outputs of any assessment and investigatory activities elsewhere. In this case, on review of the available documentation, the repetitive approach to documentation led to a lack of clarity about what was done. Consequently, the care home provider needs to achieve a situation where: • All reported incidents are assessed using a structured and recognised risk assessment process that is integral to the Datix reporting system. • Where a serious incident investigation and ‘standalone’ report document is not required the care home provider needs to implement an approach whereby the outputs of any investigation work conducted is captured on its Datix system. This risk management database has the capability and capacity to deliver this. • Where a registered care home manager is concerned about the risk behaviour of a resident, and there is an underlying diagnosis of dementia, it would be prudent for the registered care home manager to seek the input and advice of the mental health provider in scoping the risk associated with the behaviour. The nearby mental health provider is a specialist organisation and risk assessing behaviour is a core competency for its staff acting in a medical or care coordinator capacity. An embedded risk assessment process could incorporate a simple range of questions, such as: • What risk behaviour was demonstrated in this incident? • What was the impact of this risk behaviour? • If the same behaviour is demonstrated tomorrow (even in a different location or with a different resident), what is the risk of a worse outcome? • If you think the outcome could have been worse, what realistically could have happened? • What safeguards or actions need to be in place to minimise the risk of this occurring again? • Can this be achieved within current resources? • Having answered these questions, is your overall perspective of risk very low/low/medium/high/catastrophic (i.e. carries a risk of death)? As part of the risk assessment process which the care home provider may develop, it will be important to ensure that appropriate professionals are involved at an early stage to ensure that any risk assessment is conducted with the requisite skill and technical knowledge and that there are agreed direct lines of communication with specialist services – in this case, specialist mental health services – so that concerns can be logged if escalation does not take place. Partner agencies will have to work with the care home provider to develop effective lines of communication.

This case highlighted an unfortunate situation where recorded communications made by one agency (the care home) to partner agencies did not result in the detailed assessment of risk that was required. The partner agencies (the GP, and social care and specialist mental health services) have reported that on occasion they: • did not review and/or receive the information provided, • considered – as a result of inconsistencies in MR’s behaviour, and thus a variation in the messages being communicated to the visiting community mental health nurse and social worker – that there was not a ‘constant’ concern about MR’s behaviour, and consequently when information was obtained from the care home during a ‘settled’ period there were no undue concerns reported and/or • did not retrieve some of the available information and/or • misinterpreted the information. There is no simple or single solution to the above. Furthermore, the features set out have been reported as a consequence of other independent review processes. Therefore, the health and social care community in Durham needs to consider how it can achieve a more robust approach and, possibly, a common framework for enhancing the effectiveness and reliability of cross-agency communications. There are communication models already utilised in the health and social care domains that already have similar principles – a situation which suggests that agreeing on one model ought not to be unachievable. Because this recommendation represents a sizeable piece of work, spanning all agencies and care homes and not only those involved in this incident, the Safeguarding Adults Board supported by the Clinical Commissioning Group(s) within the locality are asked to jointly convene a multi-agency working party to explore possible communication models and if possible to set up a pilot scheme so that the preferred models can be tested for usability and acceptability. Furthermore, because this issue is of equal relevance to safeguarding children, it is recommended that the Safeguarding Children Board is invited to be actively involved in exploring and finding a way to improve the consistency and thus the reliability of cross-agency communications.

This case highlights a fairly common situation where one agency did not feel empowered to escalate the fact that it considered that it was not receiving a satisfactory response to requests for assistance with a resident’s management. To provide for the mitigation and minimisation of this situation in future, the Safeguarding Adults Board, Safeguarding Children Board and Clinical Commissioning Groups are asked to explore the concept of, and develop and implement, a Multi-Agency Professional Disagreement Escalation Policy. Such a policy must: • operate across agency boundaries • incorporate the need for clear local agency escalation policies that enable initial senior-management-to-senior-manager communications with the aim of local resolution • provide for the independent adjudication of multi-agency case management disputes • have a clear and understandable pathway • have a well-designed document/email template • be advertised and promoted across all agencies working with vulnerable adults and children.

This case identified a lack of knowledge about the facility within the local authority to fast track a request for adhoc additional funding for additional staffing cover where interventions such as one: one observation for a care home resident is required for a period of time to maintain a safe care and home environment for all residents. Consequently the strategic manager for commissioning at the local authority is asked to explore at the first available care home managers forum how many care home managers are aware of the fast track process to secure a temporary uplift in a residents funding package following an incident that requires enhanced care or intensive observations to secure safe care and practice including 1:1 observations.