Safeguarding review states lessons can be learned from tragic case of Milton Keynes woman who died after 'self-neglect'

A lengthy Safeguarding Adult Review (SAR) has been held into the sad case of a Milton Keynes woman who died after suspected self-neglect.

The 57-year-old, known only as ‘Adult E’, had a significant medical history which included historical and recent conditions, including ischemic heart disease, chronic obstructive pulmonary disease, chronic fatigue syndrome, dropped head syndrome, and partial paralysis following surgery.

The purpose of the SAR was to determine what the relevant agencies and individuals involved might have done differently that could have prevented her death.

Adult E had surgery in 2019 to stabilise her spine, but afterwards she suffered partial paralysis and lost her ability to mobilise independently, states the review report.

She had further admissions to hospital for treatment of infections and respiratory failure and was then admitted to a nursing home.

But within days Adult E and her family said they wanted her to be home. As a result, she returned home in March 2020 with funding for her package of care, including her mother’s help and District Nursing support.

The report, conducted by an Independent Health and Social Care Consultant, described Adult E as “a bright woman who knew her own mind” and had difficulty adjusting to life following her paralysis.

It adds: "Adult E and her mother held on to the belief that Adult E would recover and eventually be able to walk again, despite advice to the contrary. As time went on Adult E became more frustrated and had stated she often cried herself to sleep, and that being in bed was emotionally the worst place for her.

"Over the next four months Adult E continued to make her own decisions about bed rest and concordance with care. During this time safeguarding referrals were made, and professionals meetings convened in relation to risks of self-neglect..”

The patient suffered severe pressure ulcers and was meant to have five visits a day from carers to treat these. But the visits did not always happen and she also failed to receive physiotherapy promptly.

The report states: “It has become clear that Adult E was not receiving her five calls per day...A pattern had emerged where this was not escalated or visible to commissioners of the package of care... Calls were requested for early in the day, and later in the evening, and were cancelled or missed.

"The outcome of this could potentially be long periods without care, and the associated risks were at risk of being hidden.”

On July 29 2020 Adult E was found unresponsive at her home. She died in hospital the following day .

The review explains that the protocol for safeguarding status focuses on identifying neglect rather than self-neglect.

“As a result, Adult E’s case was not referred for safeguarding when arguably her pressure ulcers were a sign of self-neglect (a form of abuse under Care Act 2014) although not neglect.”

Lessons can now be learned from her case, states the report.

The city’s MK Together Safeguarding Partnership said: “This comprehensive review identified that practitioners did everything they could to engage Adult E who remained autonomous in decisions she made and had the right to make.

They said professionals had identified “all possible learning” from the review and all recommendations would be followed.