Review Opportunity

Gateshead Safeguarding Adults Board seeks an independent reviewer for a Safeguarding Adult Review

The SAR is in relation to a gentleman who suffered significant abuse and neglect which has resulted in an extended hospital admission in relation to both his mental and physical health.

• Adult K has eligible needs for care and support under the Care Act 2014. He is unable to independently meet his own needs and requires ongoing support to do so. 
• He was admitted to a care home in Birtley at the end of February 2024 following an extended stay in Lanchester Road hospital following detention under Section 3 of the Mental Health Act in November 2023. 
• Adult K is known to have complex mental health needs with a history of Recurrent Depressive Disorder and severe episodes with psychotic symptoms. His past medical history includes: Type 2 Diabetes, diabetic neuropathy, chronic anaemia, myelolipoma, vitamin D deficiency, inflammatory bowel disease, ileostomy, hypertension, carpal tunnel disease, Meniere’s disease, swallowing problems.
• When Adult K moved to Gateshead, he did not receive adequate support from the mental health or the podiatry services and there was evidence that the care home may have been unable to meet his complex needs.
• It is not clear whether all professionals were communicating proactively – it would appear no MDTs were held until the day on which Adult K was admitted to hospital in May 2024 when the wound on his foot deteriorated and he developed Osteomyelitis.
• Adult K’s family have described seeing him in an extreme state of poor hygiene whilst he was in the care home.  Adult K has a stoma which he self manages, the family have described seeing him covered in urine and faeces, which was often dry as if it had been there for hours. They reported seeing him barefoot, with an open wound, stepping into his own excrement, all while in 24/7 care. It is also possible that referrals not being made and appropriate support not being sought in a timely fashion has contributed to Adult K's injury. 

The Safeguarding Adult Review and Complex Case (SARCC) Subgroup would like to explore in greater detail:

• Cross boundary work and how agencies work together when placing an individual outside of their LA boundary.
• How agencies worked together to support this gentleman during his transition between local authority areas, Durham and Gateshead, in particular in relation to mental health and podiatry services.
• How agencies worked together to support this gentleman whilst a resident in a care home in Gateshead in particular in relation to mental health, podiatry services, pain and behaviour management.
• What was the impact of the referrals for mental health services and podiatry either not being made or not being picked up on Adult K, cross boundary work.
• How the care home placement was identified and managed and was this placement appropriate to meet the gentleman’s needs.
• The understanding of LPA, how this can be used by the family to refuse treatment for a relative.
• If the Tissue Viability service were involved and asked to give an opinion at any point whilst Adult K was in the care home.  Did he have leg / feet ulcers at the time of admission, and if so what was the management plan?

The SARCC would like to use SAR in Rapid Time (SCIE) methodology for this review, to analyse the case and to formulate an action plan to improve practice in safeguarding both within in Gateshead and in cross boundary working.  

How to apply: 

The questions to apply for this review will be sent to you when you express an initial interest in the review. Express an initial interest in this opportunity by clicking here to send us a whats app message. You can also ask questions and receive our support using this link.

The deadline for receipt of your application is midnight on 5th November.

Documents in support of your application will be received via our reviews inbox: [email protected].