Services failed man with brain injury who took his own life, finds review

A man with brain injuries who took his own life did not receive proper support from health and social care services, a serious case review has found.

Forty-three-year-old Tom, who had sustained a brain injury in a car crash more than 20 years previously, was discovered dead at his Somerset home in June 2014. Since his accident he developed longstanding mobility, mental health and substance misuse problems. More recently he had been financially exploited.

In October 2013, Somerset Partnership NHS Foundation Trust’s crisis team assessed Tom as being “a ‘low risk’ of deliberate self-harm, accidental self-harm and suicide” following a referral by police. Around the same time his family wrote to their MP complaining that both adult social care and mental health professionals were failing to perceive him as a vulnerable adult.

The serious case review concluded that the NHS trust, Somerset council and local drug and alcohol services failed to provide an integrated response to Tom’s needs.

“Services do not easily respond to individuals whose lives appear chaotic and who are barely compliant. Working with people with multiple and complex needs, across agencies, has to hinge on coordinated assessment, care management and working with the risk of harm together,” the report found.

“Tom’s family grieved for him throughout his post brain-injury circumstances – which became increasingly unsafe – and yet their requests for help did not result in integrated working.”

Lack of professional curiosity

Tom was first assessed by social services in June 2000 but the review found no documents remained to evidence the process or the outcome. At the time Tom had already referred himself to Headway, a brain injury support organisation that the review found was one of the few points of stability in his life. He disclosed an “under control” drug habit to the organisation.

In 2005, Tom told a psychologist he used drugs and alcohol “to numb” his mind. He was referred to drug and alcohol services and asked to record his use of substances and his mood.

“Tom’s family were concerned that he was in contact with many professionals and yet ‘he could not take anything in,'” the serious case review found.

“It is his family’s perception that professionals believed they were engaging with a man who was mentally capable following his rehabilitation and processes of compensatory adaptation. However, Tom was experiencing chronic insomnia after his brain injury. He was plagued by depression and, unsupervised, his addictions compromised his cognitive abilities.”

At no stage, Tom’s family explained during the review, did health or social care professionals ask about his life prior to his brain injury.

In his teens he had won a scholarship to a prestigious school before becoming involved in drug use and minor criminal behaviour.

“Although the gap between the vibrant capability of his pre-brain-injury and his post-brain injury disability was most evident to his family, ‘we were never privy to any of the assessments… after the injury he didn’t see the point of living,'” the review noted.

During 2006, however, Tom moved in with his partner Liz, who also had a brain injury and paid him £100 a week to care for her. Looking after her needs “gave him a purpose”, Tom’s family told the review.

‘Missing the subtleties’

Over the next few years Tom’s physical and mental health continued to deteriorate. He suffered chronic pain and insomnia, which he used heroin and alcohol as well as prescription medication to treat, and had a number of accidents while intoxicated.

A May 2012 adult social care assessment, the case review found, was inadequate owing to the lack of a holistic evaluation of Tom’s ability to manage risk. The assessment had a “limited” study of his mental capacity and – in common with other assessments – failed to explore his role as Liz’s partner and carer.

Professionals “missed the subtleties of his condition by dealing with bits – no one put the whole picture together and saw him as a depressed, vulnerable man who was brain damaged with mental health problems exacerbated by drugs and alcohol,” Tom’s family told the review.

In early 2013, two other drug users moved into Tom and Liz’s home and, according to police intelligence, took money from the couple. Two social workers who offered help with personal care and domestic tasks around this time were turned away.

Tom’s family recalled that a May 2013 case review called for an “emergency care plan” owing to Tom’s increasing inability to care for Liz because of his disabilities and substance use but that “nothing was ever done about this”.

‘No support or assistance’

In the year leading up to his death, Tom was denied a hip replacement operation because of his habitual intoxication.

In early October 2013 he was “found out in the street naked, shouting and screaming at Liz”, the review heard. Tom’s family stated that adult social care offered “no support or assistance” to him; nor did they investigate claims that he had been extorting money from Liz by threatening not to care for her.

Following the mental health crisis team’s decision not to provide a service, Tom was evicted from Liz’s home in late 2013. He spent the next six months living between a series of short-term homelessness placements. During this period, primary care made a safeguarding referral that was knocked back, on the basis that adult social care was already providing support around rehousing.

Tom was eventually offered a bedsit in May 2014, with social workers vouching for his ability to live independently despite carrying out no formal assessment.

But soon afterwards, housing officers submitted a further safeguarding referral stating that he was “spaced out”, being financially abused and failing to keep up with service charges. Six days before his death, adult services completed an assessment finding him at significant risk of health damage, further homelessness and “mobility limitations compromising the control of his own from door”.

In general, the serious case review concluded, “the assessment processes experienced by Tom were not integrated and had no impact on inter-professional working. Adult social care’s assessments were scant, unfocused, barely documented and disconnected from professional judgement and decision-making.”

It added that while “no single agency” could have addressed Tom’s needs, “it appears that nothing impelled or even required health and social care services to work collaboratively” to provide direction and resolution.

“A professional-led, multi-agency approach was required and this was entirely absent as gatekeeping criteria and service thresholds meant that he was placed in remained in harm’s way” the review said.

It recommended that the case be used as the basis for training in Somerset, and that ‘learning events’ for practitioners and commissioners around working with people with brain injuries.

Richard Crompton, chair of Somerset Safeguarding Adults Board, said the board had fully accepted the findings and would be giving them “continued focus and attention”.

Peter McCabe, chief executive of Headway, said: “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.”

A spokesman for Somerset County Council said: “We accept the review and its findings, and thank Tom’s family and Headway for the critical role they have played in it.

“The response to Tom’s circumstances, including the social work support, wasn’t good enough.

“Everyone is committed to learning from this and improvements have been made.”