A lack of literacy about mental health law among professionals meant they missed opportunities to safeguard a 64-year-old nursing home resident whose refusal to accept medical treatment caused his death, a safeguarding adults review has found.
The review by East Sussex Safeguarding Adults Board concerned Mr A, a former alcoholic who died in July 2016 at an East Sussex nursing home after refusing care and treatment for his many health conditions, which included diabetes, epilepsy and Korsakoff Syndrome, a chronic memory disorder commonly caused by alcohol misuse.
His sometimes aggressive refusal to accept treatment led to festering leg wounds that became infested with maggots during the final days of his life.
Lack of placements
Kent resident Mr A first entered nursing care in 2013 but after being admitted to Maidstone Hospital for leg ulcer treatment, the home refused to take him back because they felt unable to cope with his behaviour. The hospital spent nearly two weeks trying to find a home within Kent to accept him without success.
Since no home could be found, a friend to whom Mr A had given lasting power of attorney over his welfare and property, agreed to what was meant to be a short-term placement at an East Sussex nursing home.
Mr A wanted to stay in Kent but a mental capacity assessment carried out at the hospital concluded that while he had capacity to make decisions about medical treatment, he lacked capacity in regards to his discharge to East Sussex and the move was in his best interests.
In East Sussex Mr A continued to regularly refuse treatment and care despite repeated attempts to convey the dangers to his life that entailed. By December 2015 his refusal of care, which one consultant linked to “paranoid thoughts and lack of proper insight”, had caused the cellulitis on his legs to develop into open wounds.
Unlawfully deprived of liberty
At a best interests meeting in January 2016 the nursing home reported that staff “felt frustrated in the absence of advice about how to assist him” and worried that they would find him dead in his room one day. A search for a new placement was initiated following the meeting.
In the meantime Mr A’s deprivation of liberty authorisation expired but was not renewed because an email from Kent’s deprivation of liberty safeguards service with the relevant forms was classified as junk by the nursing home’s email system. Neither Kent nor the home followed up the renewal and as a result Mr A was deprived of his liberty unlawfully.
By May, with no alternative placement yet secured, Mr A’s legs had foul smelling wounds but he continued to refuse antibiotics or dressings. The consultant psychiatrist was asked several times whether Mr A could be sectioned under the Mental Health Act 1983 so he could be forced to have treatment.
The psychiatrist correctly advised that sectioning must be done to enforce psychiatric care not physical care. The review said those enquiring interpreted this advice as meaning that detention under the act was not a viable course of action in Mr A’s case when they should have considered whether treating Mr A’s mental health could resolve his unwillingness to accept physical health treatment.
It quoted Sussex Partnership NHS Foundation Trust’s review of Mr A’s case as saying: “There are certain circumstances where the patient’s mental disorder, i.e. Korsakoff’s Dementia, affects their ability with regard to refusal of physical health conditions, where the Mental Health Act can be used to treat both mental and physical health needs.”
No alternative placement for Mr A was found. By 22 July Mr A’s leg wounds were infested with maggots that would drop on the floor as he walked around the nursing home. The GP contacted by the nursing home about the maggots raised a safeguarding referral after being advised by the on-call consultant at Eastbourne & District General Hospital that care could not be imposed on Mr A and admitting him to hospital would not help.
On the evening of 24 July Mr A collapsed and died.
The safeguarding adults review found that opportunities were missed to address Mr A’s mental health and its impact on his physical health. Issues included a lack of recorded mental capacity assessments, not pursuing the option of detention under the Mental Health Act and missed opportunities to seek clarification on Mr A from the Court of Protection.
“The missing assessments, the absence of appropriate action to secure best interests on occasions when capacity had been assessed, the deprivation of liberty without authority and the failure to seek authority for care and treatment, all indicate that Mr A’s mental capacity was not appropriately addressed and the legal requirement for decisions therefore to be made in his best interests not met,” said the review.
Nursing home staff’s conclusion that Mr A’s variable willingness to accept treatment indicated that he had fluctuating capacity to make relevant decisions, but it was not clear what lay behind this assessment. The review added: “Perhaps the variability in his apparent consent, rather than indicating fluctuating capacity, indicated an inability to translate intent into action – a common feature in self-neglect that can be associated with impairment of executive brain function, but which does not appear to have been considered here.”
The review said there also appeared to be “a lack of legal literacy” in regards to mental capacity among some of the professionals involved with Mr A, including care home staff and GPs. It recommended that steps be taken to improve training on mental health legislation including regular workforce surveys to assess staff confidence on the topic that can then inform future training.
Another criticism made by the review was that at no point did all the agencies and professionals involved in Mr A’s placements, care and treatment come together. It also said that given the cross-border nature of the case a lead agency should have been nominated to coordinate the case.
The review said the case highlighted “a shortfall of placements” suitable for adults with Mr A’s level of need that needs to be addressed at commissioner level. It also said agencies should have technology systems that alert professionals if a deprivation of liberty application goes unresolved to avoid a repeat of Mr A’s experience of being deprived of his liberty unlawfully.