Page 21 - TSAB Adult B FINAL (1)

This document was classified as: OFFICIAL

organisations to more senior managers to supervise and support staff who were involved with Josh.

6.61. When a safeguarding referral was received from the ambulance service, the referral not being
progressed due to Josh being in hospital was difficult to understand. There was no liaison with
hospital staff to understand what would be in place on discharge so that the concerns and risks would
be alleviated. Hospital records did not know about this referral due to an error by the receiving
Accident and Emergency nurse on handover from the ambulance staff. Despite that error the referral
made to adult social care should have invoked an assessment regardless of hospital admission. It can
only be assumed that, as this referral came in after the previous one from the ward, that it was seen
that the outcome would not be any different.

6.62. Provisions under the Care Act also identify that a person who is unsupported within safeguarding
processes should be entitled to an advocate. It may have been that an advocate would have been able
to understand Josh’s wishes and feelings and also to help Josh understand the various processes that
were impacting on his vision for the future not being met.

6.63. The Care and Support Statutory Guidance Chapter 14 endorses a ‘making safeguarding personal’
10
approach . It is of note that the referral from the ward and the ambulance referral had been made
with the full knowledge and consent of Josh. Use of a trusted professional from the ward or an
advocate may have been a more acceptable approach and may have afforded a better opportunity to
gather the wishes and feelings of Josh to inform a care and/or protection plan. It is not known what
the impact would have been on Josh of not hearing anything further about the safeguarding referral
from the ambulance service.

6.64. No agency or service offered a challenge to the Local Authority who did not undertake assessments or
respond to safeguarding referrals in the way that guidance suggests. The Safeguarding Adults Board
has a clear procedure of professional challenge published within this review period. It is possible that
not all professionals in organisations would know of the guidance, however all safeguarding leads do.
It is therefore important that staff alert safeguarding leads when referrals are not responded to in a
way that a referrer expects.

Learning Point 11: Self neglect is a complex issue. Practitioners need an in-depth
understanding in order to improve safeguarding of people who self-neglect in this way.
Learning Point 12: Procedures and protocols provide frameworks for multi-agency
working
Learning Point 13: All agencies must understand safeguarding processes and offer
challenge when it appears that referrals are not responded to in the way expected.

10 Making Safeguarding Personal (MSP) is a sector led initiative which aims to develop an outcomes focus to safeguarding work, and a range
of responses to support people to improve or resolve their circumstances. It is about engaging with people about the outcomes they want at
the beginning and middle of working with them, and then ascertaining the extent to which those outcomes were realised at the end.
https://www.adass.org.uk/making-safeguarding-personal-publications

21