Page 25 - TSAB Adult B FINAL (1)

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8.5. A deeper understanding of the Care Act, and in particular safeguarding and self-neglect may have led
to a forum for agencies to come together with the added element of organisational safeguarding
leads who may have given an expert and objective view. The progression of the Section 42 enquiry
using the self-neglect policy leading to a risk and vulnerability panel would have brought a wider
group of professionals together for a more robust multi agency response. A making safeguarding
personal approach could have led to exploration of family support.

8.6. It is of concern that the staff within the agency tasked with responsibilities under the Care Act
appeared not to utilise the safeguarding duties and self-neglect policy and guidance fully in the way it
was intended and identifies concerns in the safeguarding system.

8.7. None of the systems and responses involved with Josh provided clarity on any key worker role. When
there are several agencies involved, multi-agency communication is aided by a key worker role to
coordinate all multi agency communication. This is not only helpful to the person but also the other
professionals involved. Josh was not subject to any system that required a key worker. The author
would suggest that with robust use of the frequent attender process and/or Care Act processes, then
a key worker role could have been identified.

8.8. Many professionals invested their time to care for and support Josh. It is not clear that if the above
systems had been applied and understood and challenged more robustly, that the outcome for Josh
would have been any different. A review of the circumstances, however, would have led to a view
that every avenue had been tried. This was not the case and therefore leads to the recommendations
highlighted in the following section.

9. RECOMMENDATIONS

9.1. The findings identified above have been included in learning points throughout this report and lead to
recommendations for improvement.

9.2. Where agencies have made their own recommendations in their Agency Review Reports, TSAB should
seek assurance that action plans are underway, and outcomes are impact assessed within those
organisations.

9.3. The following multi agency recommendations are made to the TSAB as a result of the learning in this
case:

1. The Safeguarding System

a. TSAB must seek assurance, through a peer review, that the relevant Local Authority Adult
Social Care Service with statutory duties under the Care Act, are carrying out those duties
effectively in order to safeguard the people in need of care and support in the locality where
this case occurred. (Learning Point 15)

b. TSAB should undertake an appreciative enquiry approach and seek cases to be presented to
Board meetings where a person has been successfully protected from harm following a
safeguarding referral. (Learning Point 15)

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