Adult Safeguarding in the Modern, Multi-Agency World
12/13/2020
This article contains themes that some readers may find upsetting. We have removed identifiable information from the case study, so that the individuals and organisations involved remain anonymous.
Introduction
Zurich’s Safeguarding Risk Consultant, Marie Williams, said: “We're really hoping that this case is going to highlight how each organisation has a vital role to play in safeguarding, and how important partnership working really is. The reason why we wanted to focus on this case specifically, is because it draws out some interesting and important issues in terms of the world of adult safeguarding.”
The case
The claimant in this case, we’ll call him AX, lived in a hostel and was the victim of a tragic and fatal attack by another hostel resident in 2016.
AX was born in Iraq in 1967 and came to the UK in 2011, seeking asylum. AX had mental health issues, and he had received a diagnosis of post-traumatic stress disorder (PTSD) and Obsessive–compulsive disorder (OCD). There was also a learning difficulty diagnosis which was unresolved. He struggled with the language barrier which made it harder for him to communicate his needs or resolve problems without support. This caused real problems when trying to safeguard him, in that any contact with him by professionals would be hampered if interpreters could not be sourced.
In 2013, AX moved to a hostel that was provided by a charity (“C Trust”) who supported people with learning disabilities and mental health needs.
From a safeguarding perspective, a key focus was how effective provisions of AX’s tenancy were in controlling the behaviour of the people involved. Another important point was that the hostel wasn't always staffed on a weekend or in the evening.
Due to significant issues with the perpetrator, who we’ll call BY, AX was offered accommodation elsewhere, but he always refused, because his network of family and friends was local to the hostel.
BY was diagnosed with paranoid schizophrenia and he had an antisocial personality disorder – he was also a problem drinker. In 1991, he attacked a nurse with a knife and since then spent various periods in psychiatric hospitals.
The support that BY was receiving for his mental health was provided by the local NHS mental health trust.
BY was known to hold racist opinions. His attitude towards AX was not the result of the deterioration in his mental health; in short, he was a person with racist views who was mentally ill – rather than a mentally ill person whose racism was a manifestation of their illness. These views crystallised into a personal hatred and obsession of AX, resulting in a relentless racially motivated campaign against him.
AX felt continuously victimised by BY. There were several significant incidents between the two men which AX had reported to the police. However, little further action was taken.
In 2016, the risks significantly increased – mainly due to a deterioration of BY’s mental illness. BY made pre-meditated written threats to kill AX. BY was subsequently detained by Police under the Mental Health Act 1983 and taken to a secure psychiatric hospital, run by the local NHS trust, to receive treatment. He was later moved to a second hospital run by a private sector care provider.
BY spent a time at this psychiatric hospital, before applying for his own discharge. Neither the mental health trust nor the private hospital was well prepared for this discharge hearing, and the decision to discharge BY was based on incomplete information.
BY was consequently discharged without the appropriate risk assessments in place. There was also a breakdown in communication by the hospital and the hostel. As a result, the hostel was given virtually no warning that BY had been released and so were unable to take proactive steps to safeguard AX. BY subsequently returned to the hostel. The risks were heightened due to BY’s very agitated state and, tragically, he killed AX the next day.
Lessons learnt
Chris Webb-Jenkins, Partner at Weightmans LLP, said: “When it actually came to civil legal proceedings, there were five defendants to the claim. This is a typical characteristic of civil claims relating to adult safeguarding. There were many parties involved in this case, including, the police force, the charity who provided the hostel accommodation, the local authority, the NHS trust and a private sector hospital operator. One of the key points to take away, is that it doesn't really matter how small you might think your involvement is in a particular case, all parties play an important part.
“There were common themes of complaints arising from this case – poor planning and assessment, poor communication and poor follow up action by the various agencies.”
Key learnings from this case are as follows:
1. Ensure early communication between all parties involved in the claim, including legal, Adult Social Services and insurance. Early clarification on your insurance cover will be important.
2. Emphasis on teamwork and securing commitment from other professionals in the case. These may not be obvious parties so think outside the box. <
3. Take the lead on co-ordinating the action by the defendant agencies. For example, we decided to ease off on a legalistic approach and instead to go to mediation, and we drove that forward energetically.
4. Accept the emotional context of the claim, don't battle it. Adopt a strategy that is tailored to the emotional needs of the people involved.
5. Apologise in writing, and do it wholeheartedly and early
6. Do not expect the judge to be on your side in a case like this - expect judicial sympathy to lie with the claimants
For more information about anything mentioned in this article please contact your Risk and Insurance Consultant.
