Today (9 June) Cumbria Safeguarding Adults Board have published a Safeguarding Adults Review into the case of an 85 year old woman referred to as ‘Robyn’.
Robyn died in December 2018. She sustained a traumatic head injury in a fall at home in December 2015 which she was not expected to survive. At the time she was discharged from hospital Robyn was in a minimally conscious state. She unexpectedly survived for a further three years. She died in a local hospice after the withdrawal of clinically assisted nutrition and hydration by order of the Court of Protection.
Cumbria Safeguarding Adults Board decide to undertake a safeguarding adults review as there were concerns that partner agencies could have worked together more effectively to protect Robyn.
The full report can be found at http://www.cumbriasab.org.uk/AdultSafeguarding/theboard/adultreviews.asp
Responding to the report, Independent Chair of the Cumbria Safeguarding Adults Board Jeanette McDiarmid said: “The circumstances presented in this Safeguarding Adult Review are unusual and extremely tragic. Not only have Robyn’s family had to cope with their mother’s prolonged and serious illness but also a conflict of opinion relating to her advance wishes, which ultimately lead to the decision to withdraw clinically assisted nutrition and hydration being made at the Court of Protection.
“I would like to convey my sincere sympathy to Robyn’s family at this extremely difficult time. I would also like to thank them for their support and contribution to this safeguarding adult review and I fully understand that is not easy for those who have lost a loved one.
“The purpose of a Safeguarding Adults Review is to identify lessons learned from a case, particularly in relation to how professionals and organisations can work more efficiently together. This review highlighted a number of areas for learning and improvement, including: the process for managing and communicating Advanced Decisions; how areas of the Mental Capacity Act were interpreted and practiced, specifically best interest discussions; and how multiple safeguarding concerns were managed and reviewed. I believe that these are fundamental areas of safeguarding which all partners must strive to improve.
“Cumbria Safeguarding Adults Board and individual board members have fully accepted the recommendations within this report. The board is currently developing an action plan to ensure these recommendations are embedded across the relevant organisations and that changes are made quickly to improve practice for the future. The board will be supporting agencies but will also challenge them to demonstrate what has changed and how future risk is being minimised”
Louise Mason-Lodge, Acting Director for Nursing and Quality for NHS North Cumbria Clinical Commissioning Group, said: “We would like to apologise to all members of Robyn’s family for the very difficult and distressing experience they have had. We fully acknowledge that the experience of Robyn and her family was not what we would have expected it to be, and has highlighted a number of areas where we need to improve, especially around collaboration when care is needed over a long period of time.
“Since this case we have made improvements to support how Advanced Directives are recorded, and how individual can be supported to be explicit about their wishes, both in the conversation with their GP, as well as how it is shared with all those that need to know. This work has involved us supporting GPs to encourage individuals to have clear conversations with their families to share their wishes. We have also been involved in work to better connect patients records for all health professionals as part of the Great North Care Record.
“As a CCG it has reinforced the focus we need to have around the commissioning of effective end of life services in the home, community or hospices, and how we ensure that this needs to be part of our collaborative work with all of the agencies involved to ensure every individual has the death they would hope for.”
Dr Rod Harpin, Interim Executive Medical Director and Responsible Officer North Cumbria Integrated Care NHS Foundation Trust, said: “We extend our sincere sympathies to Robyn’s family at this very difficult time. Following the investigation into her care the Trust has made improvements to the discharge planning process, undertaken considerable work to improve safeguarding training for our clinical teams and have worked hard to ensure staff are aware of how to raise safeguarding concerns. We will continue to work with our partners to ensure information is shared in a way that supports the best outcomes for our patients.”
Cath Whalley, Assistant Director for Adult Social Care, said: “This was a complex and very sad case and our thoughts are with Robyn’s family. We acknowledge the issues raised in the report and have made changes to how we work since the events detailed.
“These include changes to how we handle safeguarding referrals to ensure timely response, strengthening the arrangements in place to share relevant information between agencies when people are in need of help and implementing routine joint operational review meetings with the police and health partners.
“In addition we have created a new dedicated Safeguarding Adults service to oversee all safeguarding adults contacts and concerns. The service also works to develop and improve the delivery of safeguarding adults work across Cumbria, and to improve the wellbeing of people impacted by safeguarding concerns.
“Safeguarding is a priority and these changes significantly strengthen our approach.”