Toward Better Practices: Insights from the Trevor Serious Case Review in Learning Disability Care

Introduction

The serious case review (SCR) to be focussed for analysis is regarding Trevor who is a 51year old individual suffering from various health complications and died by attempted suicide in June 2019. The SCR was approved on February 2021 and developed by Alan Critchley on reviewing of Trevor’s healthcare delivery provided from 1 March 2016 till his death in June 2019. It covers the initial period of safeguarding referral to care delivery by the Kent County Council to Trevor through his death. The nature of the SCR is the presentation of the review of care support and abidance to policies as well as legislation along with its implication in care for Trevor to determine how they influenced his health irrespective of which he attempted suicide (kmsab.org.uk, 2021). The reason behind the choice of analysing SCR of Trevor is the development of the professional experience of the way to execute impeccable team working and communication with learning disability adults to ensure their good health so that they do not intend to suicide and face death. This is because in the care support of Trevor who is a learning disability individual it was seen that instead of professional support being provided to him during the entire tenure of care there were few misconducts which may have led to his hindered care and led him attempt suicide (kmsab.org.uk, 2021).

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The SCR of Trevor is selected for analysis because of personal interest of the way instead of development of multi-disciplinary and collaborative care for the patients, the nature of approach in the care is needed to ensure better mental health of the adults so that they can cope with long-term condition and hindered well-being. It is also chosen to determine the evidence to be developed in care environment of learning disability patients so that better care support can be provided to them for the safety of their life. The overview key findings of the SCR mention that Trevor is a white British male for whom various agencies worked together overtime but was not able to prevent the death of the patients irrespective of the collaborated support. The findings also mention that self-neglect though was identified, but there was lack of effective analysis of risk assessment and measures to be taken to prevent his mental health adversities. Moreover, findings mention lack of effective prioritisation of the patient in framing the care plan and delivery of care to Trevor which may have influenced his poor health at the end.

In this context, the three key themes to be explored are mental health risk assessment in care, collaborative and multi-disciplinary care delivery and prioritisation of patients in framing care practice. The implications of the findings from the analysis of SCR in future would be improve multi-disciplinary care delivery, improve risk assessment of patients in care and enhanced health evidence and records use in developing impeccable and quality care plan for adults with learning disabilities.

Mental health risk assessment and management for patients

The serious case review (SCR) of Trevor informs he has attempted suicide twice that is in 2011 and in 2013 regarding which information were never shared or discussed to make mental health assessment of the patient in later care (kmsab.org.uk, 2021). According to Goñi-Sarriés et al. (2018), a previous suicide attempt is clinically relevant factor for complete suicide in an individual. This is because previous suicide attempts expose the mind to develop increased long-term depression, anxiety and stress which makes the individual vulnerable to attempt complete suicide to overcome the misery of life. As argued by Lindh et al. (2019), lack of continued care support from social care workers by linking previous suicide attempts in people makes them compromise the care delivery and protection of the patient. This is because without detailed history of self-harm and reason for suicidal tendencies, the social care workers are unable to understand the weight of the prevailing mental health of the patient to be influenced by previous situations. In case of Trevor, a similar approach was seen in which no assessment regarding the level of self-harming attitude in him was done by the social care agencies. They did not link the two previous suicide and neither determined the mental health impact to be created on Trevor due to subsequent amputation in the leg and ranging health issues.

The role of social care workers in mental health management of the patient involves assessing, planning and delivery of variety of mental care services. It includes developing a partnership with psychiatrists and psychologists in developing counselling opportunities for patients, advocating patient’s needs, collaborating with families and community members in delivering mental health support to patients and others (Hou et al., 2020). This is because social workers are key individuals who act to identify the needs of individuals in different stages of life and advocate for them to improve their well-being (Mohindra et al., 2020). In case of Trevor, the mentioned role was found to be ineffectively played by the social workers which is evident as on 1 October 2018, when he was assessed face-to-face by the Community Mental Health Team (CMHT) Social workers, no confirmed diagnosis was made by using appropriate tools whether he is facing psychosis or not. They determine Trevor to be facing psychosis based on the prevailing symptoms and prescribed anti-psychotic medication use for his condition. As argued by Au-Yeung et al. (2019), without an effective diagnosis of mental health problems, the effective prescription of medication to resolve the health issue could not be made. It leads to raise error in clinical support towards the patient and leads towards hindered health as well as well-being developing in the individual. Thus, it can be suspected that due to lack of mental health diagnosis of Trevor, the effective medication which could have entirely resolved and controlled his mental health was unable to be provided that led this mental health problem to prevail resulting him attempt complete suicide.

In the UK, secondary mental health services are available such as psychological wellbeing services, community mental health teams (CHMT), home treatment and crisis resolution team and others. They are provided to mentally ill patient in referral by general practitioners to reduce the risk of stress, anxiety and other mental health issues for the patient after being discharged from the hospital (Wadoo et al., 2021). As argued by Ottisova et al. (2018), lack of secondary mental health services leads carers unable to improve the mental health of the patients for long-term condition. This is because the secondary mental health services help in providing structured care for patients at increased risk of mental health issue. In case of Trevor, it is seen that though he has history of existing and long-term mental health complications, yet the secondary mental health services were not arranged for him. It may have instigated hindered mental health management of the patient that gradually led him to fail in controlling emotions and successful in complete suicide. There was no specific reason provided regarding why the secondary mental health service is restricted for him even though his health condition indicated the need for such services.

In social work, the Crisis Intervention Model is used for clients which are experiencing trauma or crisis and for individuals who require effective intervention for prevention of suicidal tendencies and self-harm (Zhang et al., 2020). In case of Trevor, the model is applicable as he is found to be suffering from suicidal tendencies and has been diagnosed with self-harm. However, the social workers caring to arrange support for Trevor never implemented the model is intervening services to resolve his mental health crisis. According to the model, the initial step is executing psychosocial and lethality assessment of mental issue (Gönültaş et al., 2020). This is because the assessment helps in determining the level of the psychological problem faced by the patient and the nature of the problem is able to be detected. However, in the entire care scenario of Trevor, the social workers as well as the other healthcare professionals never performed any mental health assessment and only speculated his mental issues based on symptoms for which medication is prescribed on the basis of the assumptions.

The crisis intervention model mentions that effective rapport is to developed with the patient and the cause of the major mental health crisis is to be explored to determine the nature of care to be provided to them (Leiba, 2018). As argued by Berg-Weger and Morley (2020), failure to develop rapport with mentally-ill patients leads the nurses or carer to fail to identify their needs and demands to be fulfilled. It causes hindered showcase of value towards the patients and deliver of satisfactory care. In case of Trevor, the social workers are found to show effective rapport with the patient but were unaware of the causes leading to the development of mental health issues such as psychosis and depression in him.

The crisis intervention model mentions allowing mentally ill patients to express their emotions and feelings, determine safe alternative for coping health issues, create action plan and develop follow-up of interventions made for the patient (Gönültaş et al., 2020). This is important as it helps the carer determine the emotional condition of the patient regarding the health issue and effective intervention to be made for their health improvement (Behera and Jena, 2020). The follow-up of intervention helps to determine impact of the care on the patients to resolve their mental health issue (Payne, 2020). In case of Trevor, the carers supporting his mental health condition are seen to allow him to express his feelings and emotions regarding health and care but were seen not to develop follow-up investigation of the care delivered. This led the social care workers supporting Trevor unable to determine the success of intervention made for him and determine the additional changes required for his steady mental health improvement.

Collaborative and multi-disciplinary working of the social care agencies

In working collaboratively to safeguard vulnerable individuals, one of the skills involves making clear and thoughtful communication by carers and professionals of the social care agencies with one another and service users. This is because effective communication between the agency staff and nurses along with carers helps in creating substantial level of awareness of the patient’s needs and condition (Ellington et al., 2018). As argued by Burgener (2020), lack of effective communication between carers and staff of the agencies and care environment leads to create a non-cooperative situation. This is because it creates lack of awareness of the shared goals of care to be achieved, awareness of the current patient condition and the role each of the agency members are to play for the betterment of well-being of the patients. The other skills of collaborative working include presence of effective organisation skills and long-term thinking. This is because enhanced organisation helps in delegating roles and responsibilities of care to capable individuals or staff as well as ensure effective availability of resources to be used by them in completing the work within time instead if any workload (Karam et al., 2018). In addition, long-term thinking helps the staffs involved in collaborative practice develop envision the result of collaboration. It makes them develop shared vision and purpose to perform their work and understand the way their contribution is going to enhance the care delivery process and makes them adaptable to the situation to work collaboratively (Schot et al., 2020).

In case of Trevor, noteworthy clarified interaction between the St Thomas’ and Guys, the Community Care provider and the KCC Community Warden Services. They were also seen to have effective long-term thinking and organisation skills which assisted them in determining the shared purpose of care for Trevor is to improve his mental and physical health to safeguard him from suicide. It led them to act in good collaboration for Trevor which is evident as the KCC Community Warden on getting report of declining health of the patient by his friend visited him and found his pale and withdrawn condition of the foot (kmsab.org.uk, 2021). The Community Warden arrange transfer of Trevor to the St Thomas’s and Guys who acted to amputee the toe and manage the pain of Trevor in the leg caused by gangrene formation out of diabetes. At the same time, the community warden interacted with Trevor to determine way to keep his flat tidy and clean so that he is able to live in a healthy environment (kmsab.org.uk, 2021). The St Thomas’s hospital was also seen to collaboratively engage with the Adult Social Care Services in arranging post-care support for Trevor after the surgery. However, the notable gap in collaboration was identified between Adult Social Care services and Mental Health services in April 2019 when they failed to effective form intervention in resolving the physical and mental health needs of Trevor (kmsab.org.uk, 2021).

The process of collaborative working includes determining desired outcomes and actions for the patients followed by specifying roles to be played by each individual and establishing criteria for them to be followed to make consistent decisions in reaching the care goal (Scott et al., 2021). It is argued by Alagar et al. (2018), failure to reach specification of role to be played by each individual involved in collaboration create conflict and disrupted execution of services. This is because without clarified roles, the individual acting in collaboration are confused regarding the part they have to play in the care process to effectively support the well-being of the patient. It is evident from the working of the Adult Social Care services and Community Mental Health Services for Trevor. For example, the lack of collaboration of Adult Social Care with the St Thomas’ hospital and Trevor led them to develop confusion and misunderstanding regarding discharge process and care support to be provided to Trevor. It is evident as the Adult Social Care was seen to perform cleaning of the apartment of Trevor without presence of agreed proof of the action from him. Moreover, they were seen to be unaware of the actual discharge date of Trevor from the hospital and was only aware of the date when the St Thomas’s hospital contacted them on the day before of the discharge (kmsab.org.uk, 2021).

The lack of appropriate collaborative care for the mentally-ill patients makes them experience fragmented care leading to insecurity and frustration towards managing health condition (Javed et al., 2020). In case of Trevor, though he was mentioned to be an unwell individual who was unable to be prevented from taking his life by suicide, but collaborative care withdrawal in his end days may have contributed towrads his death out of insecurity to management his health. It is evident as in the last few weeks of Trevor’s life, it was seen that he was mentioned to be ineligible further for any mental health care support by his general practitioner. Moreover, he was also made aware that is no more allowed to access collaborative care from the Adult Social Care council and additional Mental Health Care agencies as he was deemed to be sound in mental health. It may have led Trevor to feel insecurity regarding his further health management out of lack of collaborative support for agencies leading him to take his life (kmsab.org.uk, 2021).

The hindered collaborative care causes inadequate rehabilitation of the patients which lengthen their stay at the hospital for care (Ma et al., 2018). In case of Trevor, it was seen that he was required to be discharged from rehabilitation centre on 7th November 2018, but his discharge was delayed till 19th November with no specific reason been cited by the authorities (kmsab.org.uk, 2021). However, it can be estimated that lack of collaboration between the members at the rehabilitation centre may have delayed the fulfilment of discharging process of Trevor which resulted in his extended stay at the hospital. As argued by Nyström et al. (2018), argument and conflict of responsibilities between care agencies leads to hindered collaborative care. This impacts to create poor outcomes for the patient. It is evident from the care context of Trevor where it was seen that there is lack of agreement between Adult Social care and Community Mental Health agencies to take care of Trevor which led them to develop argument which of them has the basic responsibility in supporting care for the patient. It led to hindered joint assessment and delivery of appropriate care contributing to deteriorated health management and outcome for Trevor (kmsab.org.uk, 2021).

Hindered prioritisation of patient in care

In delivering effective person-centred care, the role of the nurse, carer and social workers is to prioritise the needs of the patient and provide them care by honouring the rights and respecting them. This is because it makes the patient feel valued in care and make them feel to be considered in the centre of the care environment (Jobe et al., 2018). In case of Trevor, in many instances prioritisation in care was not achieved by the carers due to which less value was showed for him that may have led him to feel left out and attempt complete suicide that led to his death. The NMC Code of Conduct mentions that in making patient feel prioritised in care environment, they are to be actively listened to by the carers or nurses regarding their preference and concerns of health (NMC, 2018). As argued by Chichirez and Purcărea (2018), failure to actively listen to the patient needs and demands in care leads the carer or nurses unable to create holistic care support for the individual as well as disrespect the patient. This is because active listening to the patients makes them feel valued by the carers or nurses. Moreover, it helps the carers or nurses develop self-knowledge regarding the patient’s needs and develop trusted relationships with the patient to offer them quality and holistic care support based on their identified needs and demands.

In Trevor’s case, the Independent Chair mentioned that in many instances the professionals, carers and nurses working with Trevor failed to listen to his needs and developed hindered communication though there were few exceptions. It is evident as the due to speech development issue he used to remain quite and workers caring for him belonging to different agencies mentioned difficulty in communicating with him. This led to create distance between the agency carers and Trevor to actively listen to his needs and care for him. Moreover, in another instance, when the Mental Health services were stopped for him, the agency never bothered to actively listen to Trevor if he requires additional support or need extended assistance to manage his mental health which may have contributed to the hindered mental health and suicide of the person. In prioritising patient in care, the carers are required to encourage and empower patients in sharing decision regarding their treatment and care. This is because it makes the patients feel ability to manage their own care and achieve motivation in making enhanced decisions for their well-being (Skirbekk et al., 2018).

The study by Angwenyi et al. (2019) criticises that lack of empowerment and encouragement of the patient in care leads them to experience hindered confidence in taking their own care. This is because they feel lack of control over decisions and the ability to make individual choices. In case of Trevor, in most of the cases, the carers in the agencies took care decisions on his behalf without interacting with him or encouraging him to provide informed consent. One such instance is when the Kent County Adult Social Care decided to clean the flat of Trevor without accessing any permission for the act which is evident from the lack of any record of permission for the action. Moreover, in the care at the hospital, Trevor was never asked about the preference of care and was empowered to take his own insulin shots properly. This neglect may have led Trevor to perform increased insulin injection unknowingly while living alone that led to his death.

The NMC Code of Conduct mentions that patients’ physical, social and psychological needs are to be effectively assessed by the nurses and care response is to be made accordingly to improve their health (NMC, 2018). It makes the patient feel prioritised in the care as special attention to their needs and demands are made leading to promote their well-being and prevent ill-health (Yeh et al., 2018). As argued by Kitching et al. (2020), lack of health assessment of the patients leads the carers unaware of the specific health needs to be fulfilled and way nature of care is to be changed to effectively promote their well-being. It is evident from the case of Trevor where effective health assessment was never done to determine the level of his learning disability and whether he is at all dyslexic as demanded by his friend who are taking his continuous care apart from the agencies. It led the agencies and carers supporting Trevor’s care remain unaware of the way changes in healthcare is to be made which would help him to involve in care decision while coping with learning disability. Moreover, the lack of mental health assessment also made the carer fail to effectively prioritise the mental health and well-being of Trevor due to which he is seen to have steady unstable psychological condition which gradually may have led to his suicidal tendency.

The Care Act 2014 mentions that it is the responsibility of the local care authorities to promote well-being of vulnerable individuals to ensure their good health (legislation.gov.uk, 2014). In case of Trevor, in many instances, ineffective contribution from the local authorities towards prioritising his care was identified. It is evident as overall neglect towards his mental health assessment and management was seen from the agency care delivery. Moreover, increased disengagement of Trevor in many instances of care was seen where he was showing unwillingness or inability to mention receiving the required services. Thus, sufficient measures were not taken by the local authorities to allow Trevor to mention his required care support from own self. In the prioritisation of care for the patient, one of the common ethical challenges faced is protecting the patient’s rights and maintaining the confidentiality of the patient. This is because in making the care of the patient prior to others, the nurses may take decision on behalf of the patient which hindered their autonomous decision making. Moreover, personal data of patients may be shared unnecessarily to other with the intention of accessing support for improving the well-being of the patient (Parker and Lucassen, 2018). In prioritising care for Trevor, no confidentiality breach was seen which protected his privacy. However, violation of patient’s rights was seen such as in many instances the permission of delivering care was no acquired from Trevor and the nurses offered him care on their own terms without providing any explanation of any delay in care. It is evident from the incidences of his flat renovation and discharge from the hospitals.

The other ethical challenge raised in prioritising care for the patient is the conflict of interest between the carer and patients. This is because the carer and patients have different way of thinking which leads to create conflict in determining the way the care of the patient is to be provided (Talaee et al., 2020). In caring for Trevor, no conflict of interest was mentioned to be raised as there were few communications made with the patient in achieving informed decisions for his care. The patient safety is another ethical challenge raised in caring for service users. This is because in arranging care, the carers or nurses may avoid performing risk assessment to ensure taking measures in protecting the patients from any hindered care (Goolsarran et al., 2018). In case of Trevor, it was seen that patient safety was compromised in care which is evident as no risk assessment regarding his mental health and physical health was performed. It led the carers remain unaware of the previous suicide attempts of Trevor and fail to impose safety measures to avoid him from taking further attempt to end life which led to his death.

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Conclusion

The analysis of the serious case review informs that mental health assessment and management was poor controlled in case of Trevor by the social carers and nurses and other professionals involved in his care. They were seen to fail to arrange secondary mental healthcare services without any explanation for Trevor which was required to improve his health. They also neglect to perform any mental health assessment of Trevor to determine his mental efficiency and the nature of extended support required to improve his psychological condition. In the caring for Trevor, ineffective collaboration between multi-disciplinary team and agencies are seen in some instances due to which enhanced care was unable to be provided to Trevor. The hindered collaboration led to delay in discharge from hospital, ensure promotion of effective well-being, continued care and others. The ethical challenges faced in the prioritisation of care for Trevor include patient safety, honouring rights of the patient and informed consent. Moreover, ineffective health assessment and lack of holistic care was seen in case of Trevor that hindered his care prioritisation in the care environment.

Implication of practice in future

In the future, in similar condition, the key implication would be promoting active and clarified communication with the patients by the carers. In case the patient has learning disability, the carers are made to execute assessment of their communication capability to determine their level of effectively in supporting communication and accordingly tools are to be used in enhancing interaction with them. Moreover, in future, the action to be implemented is making agencies work collaboratively in such a way so that each of them is aware of the complete needs and demands of the patient at all level of care. This is to ensure the patient receive effective holistic care which would promote their well-being and good health. Moreover, mental and physical health assessment of each patients is to be performed to determine their psychological and physical needs and demands so that appropriate care can be arranged for their holistic support. This is required as mental and physical health are inter-related due to which both are to be managed at same level. In future, effective risk assessment of the care environment and care services provided to the patient is to be made to develop measures in reducing identified risk that would promote better health of the patient.

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