Learning from alcohol-related safeguarding adult reviews - PowerPoint Presentation

1. Learning from alcohol-related safeguarding adult reviewsPresentation for alcohol change ukNovember 2020

2. The first national analysis of SARsCommissioned by CHIP - the sector-led Care and Health Improvement Programme co-produced and delivered by the Local Government Association and the Association of Directors of Adult Social Services in EnglandAuthors: Michael Preston-Shoot, Suzy Braye, Oli Preston, Karen Allen and Kate SpreadburyProject Oversight: Adi Cooper, CHIP

3. My aim today

4. Methodology

5. The analytic framework: five domains

6. 2. The 231 cases: demographics263 individuals, 80% deceasedCause of death - alcohol intoxication and liver disease (n=11)129 male, 109 femaleAverage age 55Little information about sexuality or ethnicity Range of health concerns and complex interplay Physical comorbiditiesPhysical and mental ill-health + significant life eventsSubstance misuse (alcohol and other drugs) (n=64; 28%)Living situations: Living alone (36%)Group care (33%)Location of abuseOwn home (48%)Residential/nursing care (18%)PerpetratorSelf (48%) Care providers (30%)

7. The 231 cases: types of abuse/neglectType of abuse/neglectReviews n %Self-neglect 10445.02%Neglect/omission8536.80%Physical abuse4519.48%Organisational abuse3314.29%Financial abuse3012.99%Domestic abuse229.52%Psychological abuse 19 8.23%Sexual abuse 12 5.19%Sexual exploitation 5 2.16%Modern slavery 2 0.87%Discriminatory abuse 2 0.87%Other114.76%Not specified 2912.55%Modern slavery/sexual abuse/ sexual exploitation more prevalent in younger subjectsNeglect/abuse by omission more prevalent in older subjectsPsychological/emotional abuse and modern slavery more prevalent for femalesFinancial, physical abuse and self-neglect are (slightly) more prevalent for malesNo correlation with types of abuse/neglect subject to s.42 enquiriesSome types of abuse/neglect positively correlated with each other (e.g. domestic, financial, physical and emotional abuse); some appear unrelated to other types (self-neglect, neglect/omission)

8. Alcohol-Related SARs57 cases (25%) where the principal focus was on a person with alcohol-related concernsCorrelations with self-neglect and/or homelessnessExamples of fire deaths involving alcohol abuseImpact of loss and traumaAdditional 5 cases where someone in the person’s environment was alcohol-dependentHighlights the importance of thinking family (domestic abuse, impact on children, understanding family and relational dynamics)One case of a paid carer being alcohol-dependent

9. Good practice across the domains

10. Examples of good practice in alcohol-related reviewsThorough and robust care and support, risk and/or mental capacity assessmentsRoutine monitoring of, and treatment for physical health issuesLiaison with drug and alcohol teamsInformation-sharing

11. Poor practice across the domains

12. Practice shortfalls noted in alcohol-related reviewsDirect practiceSuperficial or missed assessments (impact of alcohol on capacity)Focus on single issues rather than holistic (risk) assessmentLack of think family approachLack of curiosity (History)Reliance on self-reportLabelling and prejudice, assumptions about life-style choiceAlcohol abuse not seen as self-neglectPartnership workMental health and drug and alcohol services not working togetherInflexible thresholds and referral bouncingLaw seen as complex (mental capacity and alcohol-dependence; mental health and alcohol-dependence)Absence of safeguarding referralsService responseLoss of servicesLack of services (mental health support; supported accommodation; outreach)Lack of policies and protocols to guide staffNeed for training Need for more robust, humane and flexible approach

13. Recommendations across the domains

14. The national contextDo SARs give sufficient attention to the legal, policy and financial context in which safeguarding practice takes place?Notable issuesTarget bodiesImpact of austerityDepartment of Health & Social CareLegal rulesMinistry of JusticeRecognition of impact on victimsDepartment for Work & PensionsRegulation of servicesHome OfficeStatutory guidanceCrown Prosecution ServiceCoordination of parallel review systemsCare Quality CommissionNational commissioning shortfallsNHS EnglandLocal Government AssociationHealth & Safety ExecutiveNational Probation ServicePrison Service

15. Learning from the voices of lived experienceSeeing the whole person in their situationA trauma-informed, whole system response to the person in contextThe problem is not the problem; it is the solution that is the problem. Tackling symptoms is less effective than addressing causes.Attempting to change someone’s behaviour without understanding its survival function will prove unsuccessful. The problem is a way of coping, however dysfunctional it may appear. Too often we are responding to symptoms and not causes. Put another way, individuals experiencing multiple exclusion homelessness are in a “life threatening double bind, driven addictively to avoid suffering through ways that only deepen their suffering.”

16. Using the voice of lived experience (SAR - Ms H and Ms I – Tower Hamlets SAB)In the context of people’s experiences of multiple exclusion homelessness, the notion of lifestyle choice is erroneous.The problem is not the problem; it is the solution that is the problem. Tackling symptoms is less effective than addressing causes.Attempting to change someone’s behaviour without understanding its survival function will prove unsuccessful. The problem is a way of coping, however dysfunctional it may appear. Too often we are responding to symptoms and not causes. Put another way, individuals experiencing multiple exclusion homelessness are in a “life threatening double bind, driven addictively to avoid suffering through ways that only deepen their suffering.”At times “she could not help herself” because of the feelings that were resurfacing; access to non-judgemental services was vital and helpful, and that support is especially important when individuals are striving to be alcohol and drug free. It was during these times that stress, anxiety and painful feelings could “bubble up”, prompting a return to substance misuse to suppress what it was very hard to acknowledge and work through.Making Safeguarding Personal is not just about respecting the wishes and feelings that an individual expresses.He reflected on the challenge of knowing when to allow a person freedom of movement and when, for their own benefit, to curtail or supervise this. He described this as a “moral question.” It is indeed a question that, in a multi-agency and multi-disciplinary forum, needs to be answered in each unique situation, drawing on an analysis of risks and mental capacity.

17. Milton Keynes – Adult B (2019)Adverse childhood experiences; substance misuse as response to traumaUnable to sustain hostel place due to substance misuseUnplanned hospital dischargesAdult Social care assessments of his needs arising from autism and homelessness delayed and incomplete at time of deathNo lead agency or practitioner championing his unmet underlying needsLifestyle and health concerns mount with no signs of professional scrutiny – no professional curiosityNo mental capacity assessment or full safeguarding assessmentNo use of advocacy or escalation of concernsLack of inter-agency response including multi-agency meetingsLack of management guidance, direction and supervision

18. Isle of Wight – Howard (2018)Homeless single adult without local family supportLongstanding alcohol misuse and physical ill-healthHospital and prison discharges to no fixed abodePolice and ambulance crews concerned about risks of financial and physical abuse, and his self-neglectRefused housing as not regarded as in priority needNo wet hostel availableReferrals to adult safeguarding do not prompt multi-agency meetings or investigation; no completed Care Act 2014 care and support assessment No lead agency or key worker; no risk assessment or mitigation plan No holistic approach – services in silos.

19. Carol (2017) Teeswide SABAttacked and murdered by two teenage girlsLack of understanding of coercive and controlling behaviour, of risk from otherslong history of chronic alcohol use, mental health problems and vulnerability and had been identified as having multiple care and support needsMultiple agencies involvedDiagnosed with a personality disorder - primarily Emotionally Unstable Borderline Personality Disorder (EUPD). Carol was therefore considered to have a dual diagnosis.Identified The need to develop or modify existing treatments to better meet the special needs of personality disordered substance abusers with therapeutic attention to reduce the severity of the substance abuse and other associated psychiatric problems such as depression, anxiety, paranoia

20. DiscussionHow prominent are SARs in informing your day-to-day practice?How prominent is learning from SARs in informing your team’s practice?How often might you and your colleagues discuss learning from SARs?How aware are you of SARs completed on alcohol-related issues?

21. Being Knowledge-InformedAlcohol Change UK (2019) Learning from Tragedies. An Analysis of alcohol-related safeguarding adult reviews published in 2017. London: Alcohol change uk.Braye, S., Preston-Shoot, M., Preston, O., Allen, K. and Spreadbury, K. (2020) Biennial Analysis of Safeguarding Adult Reviews April 2017-March 2019: Findings for sector-Led Improvement. (forthcoming)Cream, J., Fenney, D., Williams, E., Baylis, A., Dahir, S. and Wyatt, H. (2020) Delivering Health and Care for People who Sleep Rough. Going Above and Beyond. London: Kings Fund.Holmes, M. and ward, M. (2014) blue light project: working with change resistant drinkers. London: alcohol change uk.Nice (2011) alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. London: national institute for health and clinical excellence.Public Health England (2018) Evidence Review: Adults with Complex Needs (with a particular focus on street begging and street sleeping). London: Public Health England.Preston-Shoot, M. (2019) ‘Self-Neglect and Safeguarding Adult Reviews: Towards a Model of Understanding Facilitators and Barriers to Best Practice.’ Journal of Adult Protection, 21 (4), 219-234.Preston-Shoot, M. (2020) Adult Safeguarding and Homelessness. A Briefing on Positive Practice. London: LGA and ADASS.St Mungo’s (2020) Knocked Back. How a Failure to Support People Sleeping Rough with Drug and Alcohol Problems is Costing Lives..

22. Contact detailsProfessor Michael Preston-ShootProfessor Emeritus Social Work, University of Bedfordshire Independent Adult Safeguarding ConsultantIndependent Chair, Brent Safeguarding Adults BoardIndependent Chair, Lewisham Safeguarding Adults Boardmichael.preston-shoot@beds.ac.uk