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NSAB publishes two important SARs

Today (16 January 2020) the Norfolk Safeguarding Adults Board (NSAB) publishes two important Safeguarding Adults Reviews (SARs) into the deaths of a woman (Ms F) and a man (Mr G) who lived in a Norfolk care home. The board wishes to record their condolences and their thanks to both families for their assistance throughout the review process.

Ms F lived with dementia as did Mr G. The two residents were not related to each other in any way, and their cases are quite different. However, there are overlaps in a number of the learning themes, and NSAB agreed it would be beneficial for both cases to be reported in a joint report.

Both these SARs have important lessons for a range of agencies about the care for people who have challenging behaviour due to dementia.

Click here for the full report, executive summary and action plan (Ms F)

Click here for the full report, executive summary and action plan (Mr G)

Ms F lived with dementia in a Norfolk care home. She had lived in the care home for a number of years. The focus of this SAR begins in June 2017 after a male resident (Mr Z) moved into the care home as a private placement. Soon after Mr Z arrived at the care home he began to demonstrate challenging behaviour, including resistance to personal care, shouting and verbal aggression. Within a short time this developed to include violence towards staff members, and then to other residents. Violent behaviour included hitting or punching residents in the face/head. In December 2017 he pushed over Ms F, who hit her head as she fell to the floor and fractured the neck of her femur. After she returned to the care home following surgery, the incident and subsequent surgery seems to have set in motion a chain of deterioration in Ms F’s physical and emotional health. Although it is not for the SAR to consider causation of Ms F’s death, it appears important to note Ms F sadly died some weeks afterwards at the care home on 31 January 2018.

Mr G was an elderly man with dementia and a range of other health conditions. In June 2017 Mr G was admitted to an acute hospital in Norfolk following an incident in a previous care home, which led to him falling and sustaining an injury (not a fracture). While in hospital his behaviour became more challenging, leading to his detention under the Mental Health Act 1983. Mr G was admitted to a psychiatric hospital outside of Norfolk as there was not a bed available at the time in Norfolk. He was returned to a Norfolk psychiatric hospital some months later. After a further 3 months in hospital, Mr G was discharged to the Norfolk care home.  

The care home had significant difficulties in effectively managing Mr G and providing him with adequate care. Personal care was often refused, or delivered under challenging conditions. The Dementia Intensive Support Team (DIST), who remained in contact with Mr G, noted concerns about the care home's ability to safely manage Mr G, but this was not flagged as a safeguarding referral. Despite their concerns DIST proposed to discharge Mr G to the care of his GP, based on apparent improvement in his presentation. The relationship between Mr G's family and the care home broke down over the next 3 days regarding Mr G's care. There was significant concern for Mr G’s physical health and a paramedic was called who arranged for Mr G to be admitted back to hospital.

The ambulance crew who admitted Mr G to hospital were so concerned about Mr G’s physical state that they made a safeguarding referral, querying the possibility that Mr G had experienced neglect. The care home has disputed the concerns documented by the ambulance service, stating that these concerns were simply those relayed by the family.

Mr G sadly died in hospital 3 days later on 22 November 2017.