Practitioners lack knowledge of how to apply the Mental Capacity Act 2005 to cases of alcohol-related harm, including because of a lack of guidance, a study of safeguarding cases has found.
The research also revealed problems in social workers and other professionals’ understanding of self-neglect in relation to adults made vulnerable because of problem drinking.
The Alcohol Change UK report, ‘Learning from tragedies’, published today, analysed 10 safeguarding adult reviews (SARs) and one independent safeguarding review published in 2017 where alcohol was relevant to the death of the individual, whether as a result of health problems, killing or suicide.
Little or no engagement with services
In all cases, there was little or no engagement in services, while self-neglect was explicitly linked to alcohol use in nine cases; in six cases, self-neglect and refusal of services was the main factor leading to death.
Abuse and exploitation was a factor in six cases, and the main factor leading to death in three. The study also identified lack of family involvement as a factor in eight cases and, in six, a traumatic event triggered alcohol intake.
The report identified a range of interlocking external factors that made it harder for individuals to become and stay involved with services.
Some of these were linked to the harsh financial climate local authorities are working in – such as lack of service capacity, “prohibitively” high thresholds for support and short-term commissioning arrangements.
“Critically, the culture of short contracts and regular re-tendering in drug and alcohol service commissioning has exacerbated a problem of lost contacts and inconsistent provision,” the report said.
Poor multi-agency working and lack of ownership of people’s cases was another factor, it added. “In some cases, professionals with high workloads will refer the adult to another agency, which can lead to vulnerable adults being ‘passed around’ rather than helped.”
But in many instances a lack of understanding by individuals and services was also a factor in people not getting the support they needed, the study found.
Eight of the reviews highlighted a lack of understanding of mental capacity among frontline practitioners. In all but three cases, the person’s capacity was not assessed despite indications that an assessment was needed. For example, in three cases where the person’s capacity was not assessed, practitioners were unsure whether the adult understood the consequences of their choices.
The reviews also identified challenges in dealing with fluctuating capacity, where a person would have the ability to make decisions when lucid, but not when intoxicated. One review questioned whether a chronic alcohol user could be sober and pointed out that their ability to make decisions about alcohol intake was undermined by the addictive nature of the substance.
These issues were linked to the quality of guidance on the MCA available to practitioners. Specifically, the MCA code of practice, the statutory guidance on applying the act, does not address alcohol use other than to point out that a temporary lack of capacity may be caused by the effects of alcohol.
“The guidance suggests that if it is thought a person will be able to regain capacity at a later point, and if it is practical, then the assessor should wait to assess capacity,” said the study. “However, this is challenging if an individual continually moves in and out of capacity due to intoxication, or spends the majority of their waking hours intoxicated with some moments of lucidity. It is this dynamic that limits the application of the Act to people with alcohol problems.”
The study also identified a lack of understanding of self-neglect.
This was perceived as a ‘lifestyle choice’ by practitioners in three cases, which “prevented a deeper analysis of the underlying causes and precluded attempts to address them”.
The study also said that, among “even among those with knowledge of self-neglect, alcohol misuse is less readily perceived as [such] compared to other behaviours such as hoarding or lack of personal hygiene”.
Adult D’s story
Adult D was alcohol dependent. His mother had looked after him and when she died his father hired a cleaner. When
his father died, Adult D moved home and was self-neglecting. He had lost job and had mental health and mobility issues.
Practitioners often found human dirt covering the walls of his flat and clothes lying around which appeared to be wet through urination or covered in faeces. He consistently declined care assessments and help.
In June 2013, his GP referred him to environmental health. It was found that he had no hot water, no shower, toilet, or food in the house and his lights were not working. He agreed to go into a respite facility while his property was deep cleaned. However this did not have a long-term effect.
His mental capacity was assumed but never assessed. He had multiple long-term health conditions, such as leg ulcers, osteoporosis and diabetes. His home care package withdrew support due to his alcohol-fuelled verbal abuse of their staff. His informal carer was also drinking and suspected to be financially exploiting him.
Adult D died in hospital of sepsis and multiple organ failure due to the neglect of his leg ulcers.
‘Findings will resonate with practitioners’
Fran Leddra, principal social worker (PSW) at Thurrock council and co-chair of the Adult Principal Social Worker Network, said she welcomed the publication of the report.
“It is a compelling read and sadly the findings will resonate with safeguarding practitioners and the challenges of working with people, who for whatever reason, are described as refusing support, or are not engaging,” she said.
“It reminds us we must be persistent and creative when it is clear the cause of self-neglect is complex and involves alcohol misuse,” she added. “Our practitioners need to be well trained, and as PSWs we have a lead role in our organisations for advising on high risk safeguarding matters and disseminating the lessons learned from safeguarding adult reviews.”
Wulf Livingston, a reader in social science at Wrexham Glyndwr university specialising in alcohol and drugs, said: “There have always been problems when people are trying to assess or separate out alcohol use, that’s a clear bit that comes out of this study.
“The real challenge for social workers is to ask, ‘What more can I do to engage the individual,’ rather than labelling them as non-engaging or non-motivated,” Livingston said.
Richard Piper, chief executive of Alcohol Change UK, said: “The recommendations we offer are workable and urgent, especially for those people who are alive today and are at risk of being the subject of a future safeguarding adult review.
“Most importantly, professionals who are working hard in the most difficult of circumstances need to receive proper legal backing and much better training in how to handle the genuine complexities of an alcohol problem when it is entwined with other challenging issues.”
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