Martin was a 51 year old man who at the time of his death had been living in squalid conditions and was physically frail. The Lambeth Safeguarding Adults Board commissioned an independent Safeguarding Adults Review (SAR) to explore the learning from the circumstances of Martin’s death.
This SAR raised important issues around the link with mental capacity and self-neglect. This included key learning around the need for mental capacity assessments to explore more than what a person says they can do; “a mental capacity assessment must also explore whether the person can put these verbal claims into some sort of meaningful action, and if they cannot whether they are able to use and weigh this information to make decisions about other options” (7.1 Learning Point 1). Furthermore, there is a need for better understanding of the interaction between self-neglecting behaviour and risk to the person’s vital interest, and the need for a deeper level of professional curiosity. (7.3 Learning Point 6).
The review also highlighted issues with multi-agency communication and escalation processes. This included learning around referral mechanisms and the processes in place to respond to imminent risk (7.2 Learning Point 5).
The Lambeth Safeguarding Adults Board has agreed all recommendations from this review, and this will now be built in to a targeted action plan. This will include the development of multi-agency self-neglect policies and procedures, and communication pathways which allow for frontline practitioners to initiate urgency multi-agency conversations with all agencies involved.
The full report by independent reviewer Kate Spreadbury can be found on the LSAB website.