Page 24 - TSAB Adult B FINAL (1)

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 Ambulance service triage recognised concerns and raised them to ensure a more immediate
response and triaged time was overridden. There were further similarities in upgrading
response times in relation to perceived need.
 The paramedic safeguarding referral was of high quality and contained consent from Josh.
 The psychiatric liaison team worked well with the Acute Hospital.
 The frequent attender meeting was attended by several agencies.
 There was some good recording of discharge arrangements by staff in the acute hospital
 Capacity assessments detailed specific risks to Josh.
 The diabetes team offered a flexible service in an attempt to keep Josh engaged.
 Josh was often allowed to stay extra nights in hospital with evidence of very good caring and
provision of clothes and other essentials by the nursing staff.
 Police engaged with Josh to ensure he returned back to the mental health unit under his
terms.
 There was good communication between liaison psychiatry and the acute hospital wards.
 A lot of staff went over and above what would be expected of them to keep Josh safe.

8. CONCLUSION: MULTI AGENCY WORKING & COMMUNICATION

8.1. Notwithstanding the above good practice, it can be identified in drawing together conclusions in this
case, that learning relates to the use of systems to support multi agency working. These may have
provided a more cohesive approach to safeguarding Josh that incorporated his wishes and feelings.

8.2. In thinking about the housing issues presented in this case, there would have been a benefit from
robust communication between all of the professionals involved, including housing staff. This would
have helped an understanding of housing processes and legislation by other professionals and would
have helped housing staff to have understood more fully, the circumstances facing Josh. It is
acknowledged that since the ‘duty to refer’ has been invoked, that there is better communication
between the acute hospital and housing. The result of this review has also led to professionals
indicating that they will invite housing staff to meetings in the future, where relevant.

8.3. A multi-agency frequent attenders protocol that led to a multi-disciplinary meeting attended by all
relevant professionals may have had a twofold outcome, one that focussed on keeping Josh in
hospital for the least amount of time, and also one that focussed on action and prevention of the
issues that Josh was facing that led him to feel a need to be in hospital. A recommendation of this
review relates to possible exit pathways from an initial frequent attender meeting dependant on the
circumstances.

8.4. A more holistic approach to Josh may have led to a deeper understanding of his level of substance
misuse and how that may have been impacting on his decisional capacity and his ability to use and
weigh information that had been relayed to him. It may also have led to a deeper understanding of
Josh, the person, and that his ‘agency and control’ were affected by his personal circumstances that
were leading to the helpless situation that he declared he was in, leading to him seeing the only way
out was to end his life.

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