Review Opportunities

Nottingham City Safeguarding Adults Board

Nottingham City Safeguarding Adult Board is seeking to commission a reviewer for a Safeguarding Adult Review.

Nottingham City Safeguarding Adult Board are looking for an Independent Reviewer to complete a Safeguarding Adult Review (SAR) into a case involving a man with care and support needs in his early thirties with:

• Chronic kidney disease since birth resulting in a failed kidney transplant 2014 – since requires dialysis 3 x per week
• Autistic Spectrum Condition (ASC)
• Psychosis
• Impulsivity and self-harm
• Currently recovering from a traumatic head injury

Since their kidney transplant failed in 2014, the individual has had a number of adult mental health inpatient admissions due to experiencing psychosis and hallucinations with many incidents of significant self-harm. He was transferred from a specialist service providing nursing and personal care for those with a learning disability, autism and highly complex needs and behaviours to a mental health ward due to refusal to take prescribed medication. While there, his level of self-harm escalated to a significant level which required constant supervision and high levels of restraint. A subsequent temporary move to a High intensity Unit became more long term as there were no suitable alternative placements available. This environment is not intended for long term stays, nor is it designed to support people with autism. Their self-harming continued to escalate resulting in a serious head injury which required brain surgery.

Following initial scoping, it was felt a mandatory SAR be commissioned. Key areas of focus are:

• That their autism was not considered enough in care planning and placements
• There was lack of understanding around identifying whether their significant self-harm was linked to autism or deteriorating mental health
• They were placed within restrictive environments for a long period of time, despite it being recognised early on in their care that this would have a detrimental impact and may cause their self-harm to escalate
• There is a significant lack of MSP and their voice is not heard anywhere throughout placements and treatments
• There is apparent miscommunication on their admission to acute hospital following the most significant incident of self-harm where they were admitted to be checked for pneumonia and staff were not informed of a head injury. This meant a head scan did not take place at the time
• There was a lack of coordination meaning information was not always shared in handovers from different services/placements

The Board have expressed that they would like this SAR to follow a Systems Review model. The ‘systems’ model has been identified by Sheila Fish, Eileen Munro and Sue Bairstow as a means of identifying which factors in the work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. It is a collaborative model for case reviews – those directly involved in the case are centrally and actively involved in the analysis and development of recommendations.

How to apply:

Please provide:

- A CV

- covering letter outlining your experience relevant to the themes of the review 

- A statement that you do not have any current or historical connection to the agencies/organisations/individuals involved in the review.

Please express an initial interest in this opportunity by clicking here to send us a whats app message. You can also ask any questions and clarifications using the link as well. 

The deadline for receipt of your application is midnight on 26th February.

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