A Serious Case Review was commissioned by the Somerset Safeguarding Adults Board (SSAB) following the death of ‘Tom’ who took his own life in 2014, aged 43. Tom had sustained a traumatic brain injury in a road traffic accident in his early twenties, which left him with physical, cognitive and psychological issues. In addition, Tom had a dependency on drugs and alcohol.
The independent report published by the board today concludes that despite numerous contacts with many health and care professionals and the concerns of family members he was not provided with appropriate support.
It highlights a lack of joined up working across social care, health bodies and drug and alcohol services. No organisation took a lead role in determining a coordinated, multi-agency response and opportunities to intervene in an integrated way were missed.
The report highlights the invaluable role provided by provided by local brain injury charity, Headway Somerset, which supported Tom for more than 13 years.
The report makes recommendations about how services can best support people with multiple and complex needs, including that Tom’s case features in multi-agency training and be disseminated beyond Somerset to stimulate debate and improve multi-agency responses.
The report also calls for assistance from Headway – the brain injury association, to which Headway Somerset is affiliated, in achieving these objectives.
In June last year the report’s author, Margaret Flynn, presented Tom’s case to more than 100 professionals at an SSAB-organised, multi-agency learning event. Headway Somerset, which had provided Tom with valuable support for more than ten years, also contributed to the training.
The SSAB is a statutory partnership including Somerset County Council, Avon & Somerset Constabulary and the Clinical Commissioning Group who work together to protect vulnerable adults from harm.
Its Independent Chairman, Richard Crompton, said: “I would like to speak on behalf of the Board to express my deepest sympathy to Tom’s family for their loss. Safeguarding adults is everyone’s business and an absolute priority for the Board and its partners, as it should be for everyone, and this review has highlighted a number of areas which require our continued focus and attention.
“The review into Tom’s death made a number of recommendations, which the SSAB has fully accepted and will continue to oversee and monitor. I would like to publicly thank Tom’s family for their valuable input and involvement in working with both Margaret Flynn and the Board in helping us to identify the lessons to be learnt that will serve to prevent similar circumstances from occurring in Somerset in the future”.
Margaret Flynn said: “Tom's brain injury was as unexpected as it was sudden. Yet his family's grief and growing concerns were met with incomprehension. Tom was believed to be making unwise decisions; choosing to breach tenancy agreements; and choosing to abuse substances. Such beliefs compounded his own and his family's distress. Tom's life and death raise questions about the importance of understanding people's pre-brain injured lives and seeing them in terms of support needs. His life mattered. Somerset services acknowledge that they could and should have done better.”
The family of Tom have issued the following statement: “The review into Tom’s death highlighted several shortcomings in the care he received following his traumatic brain injury over 20 years ago.
“During Tom’s life we called on multiple agencies to help us to support him. This case review has clearly identified that Tom did not receive the support and help he was entitled to, and nor did we as a family. We thank Margaret Flynn for her dedication in identifying and documenting these issues in a formal manner.
“We would like to thank Headway Somerset for their long term support. We are eternally grateful for all they tried to do for Tom and us as a family. We hope that the safeguarding board will work closely with both Headway Somerset and Headway – the brain injury association to ensure better training for professionals in supporting the long-term rehabilitation needs of individuals with acquired brain injuries in the future.”
Peter McCabe, Chief Executive of Headway – the brain injury association, said: “We welcome the acknowledgement that mistakes were made and lessons must be learned, and note the actions that have taken place since the report was completed.
“However, the tragic reality is that Tom, a vulnerable adult, was repeatedly failed by agencies whose responsibility it was to protect and support him."
2001 Health Select Committee report 'must be revisited'
Peter continued: “As long ago as 2001, the Health Select Committee recommended that health authorities, trusts and local authorities put in place a case management or equivalent system which gives head-injured patients and carers an identifiable guide and advocate through the whole care pathway.
“It also recommended that NHS trusts and Adult Social Care departments should be required to identify named managers with responsibility for coordinating the service and ensuring inter-agency collaboration. Sadly, this important and potentially pivotal report has not been acted upon by successive governments, with local authorities provided with no additional resources or clearly specified objectives.
“Tom was not provided with such support. There was no clearly identified lead to co-ordinate and oversee an appropriate and comprehensive programme of care and there was insufficient multi-agency collaboration to meet his complex needs.
“It is vital that all local authorities take time to read and fully digest this report and learn the lessons contained within in order to ensure that no other brain injury survivors are similarly let down.”
The full serious case review report is available to read here.
Quotes from the Somerset Safeguarding Review
- 3 years old: Tom sustained a head injury when he was knocked down by a car.
- 8 years old: He had a minor head injury.
- 14 years old: had concussion and a head injury (which his family attribute to school sport activities).
- 17 years old: had a minor head injury and laceration.
- 22 years old: Tom sustained a significant brain injury resulting from a road traffic accident.
The family could not understand why neither adult social care nor mental health professionals perceived Tom as “a vulnerable adult.”
- Somerset County Council’s adult social care, Somerset Partnership Trust and Turning Point did not provide a service to a man who was brain injured, who was depressed, who could not sleep, who abused alcohol and drugs and who had expressed his intention to take his own life. Somerset Partnership Trust states that, even now, he would remain ineligible for any mental health service if he were to be referred during 2016.
- Some professional decision-making was frankly bizarre. For example, during April 2013 the independent living assessment was declined because Tom had “no permanent accommodation.” Also, during November 2013, it was noted that although Tom had been referred to Turning Point, it was unable to help because “he did not have an addiction due to ability to abstain.”
- Although his sister had been a willing advocate since 2005, she could not understand the activities of professionals and recalled being advised on one occasion that Tom was “not eligible for an assessment.” Her overall sense was that “Everyone seemed to buck pass.”
- Headway had a high tolerance of Tom’s behaviour and remained a constant in his life until he was suspended during April 2014. However, Headway did not follow its policy insofar as it allowed Tom to continue attending when he was intoxicated and long after he had been given a final warning.
- Adult social care acknowledges that its recorded evidence concerning Tom’s circumstances was scant. Headway, Tom’s partner and his family were in regular contact with his social workers and raised concerns and yet these were not reflected in adult social care records.
- It had become difficult for Headway staff to witness the trauma that the pain was causing Tom, since he “continues to be almost reduced to tears with the pain in his hip and has described his increasing use of ‘street drugs’ because the medicines he is prescribed don’t touch the pain.”
- Tom’s mother emailed a friend. She wrote “I am increasingly feeling that I am batting my head against a brick wall and that…he is going to be found dead one day having overdosed accidentally or otherwise.”
- On the same day the police summoned the ambulance service to Tom’s property. He had taken his own life.
