Page 20 - Adult C Overview Report - FINAL

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that he always made sure Adult C attended her health appointments.

7.38. When her condition worsened a couple of days later, Adult C refused hospital admission and
was deemed to have capacity to do so; assessment of capacity in this situation, as discussed
previously was unlikely to have been straightforward.

7.39. There was debate during the review regarding why Adult C may have chosen to not go to
hospital. Although the reason cannot be known, there were thoughts that maybe she had not
realised how serious pneumonia can be. The ambulance crew had not found her to be

extremely unwell and she had been seen by the nurse specialist 17 hours earlier.

7.40. When the author met with Adult 1, he indicated that he had not known about the call to the
ambulance two days before she died. In response to asking about the possible reasons that
Adult C would have refused to go to hospital, Adult 1 thought that she may have been scared.
Adult 1 informed the author that a friend of Adult C’s had recently died from pneumonia and
was in his thirties. Adult 1 stated that Adult C knew that she could be at risk of dying from
pneumonia. Adult 1 stated that he had tried to reassure her that she would not die.

Learning Point 11: Use of clinical pathways for treatment is a useful tool to aid effective
management of physical health conditions in those who are alcohol dependent and live
in complex circumstances
Learning Point 12: Pneumonia is a serious condition that can result in death even in
healthy adults. It is important that professionals convey to the person the urgency of
seeking help if a person’s condition causes them concern.

Multi agency working and communication.

7.41. This case has highlighted the need for effective communication and multi-agency working. It
is discussed above how there are significant complexities in working with those who are
alcohol dependent and are victims of domestic abuse. The risks are significant and
interventions that are likely to lead to positive outcomes are challenging. Several research
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studies and guidance , have indicated that when these two situations occur together,
professionals can find that the need for specialist intervention and advice is vital. In the case
of Adult C, she was open to services that could support her in both of these issues. It was a
feature, though, that these services did not really work together effectively. The substance
misuse service had little understanding of how MARAC worked and did not make repeated

referrals as required believing that Adult C was already known to MARAC. Neither substance

https://alcoholchange.org.uk/blog/2019/alcohol-and-intimate-partner-violence
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17 Ward, M. et al 2016 Domestic abuse and change resistant drinkers: preventing and reducing the harm Learning lessons from
Domestic Homicide Reviews
https://avaproject.org.uk/wp-content/uploads/2016/09/Alcohol-Concern-AVA-guidance-on-DA-and-change-resistant-drinkers.pdf

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