Page 10 - TSAB Adult B FINAL (1)

This document was classified as: OFFICIAL

5.34. It appears that at some stage Josh left this property and moved to a tenancy that he may have
secured by himself as there is no record that this was arranged by professionals.

5.35. Following the initial visits from the teams mentioned above, Josh attended his diabetic clinic
appointments but failed to engage in any appointments with the affective disorders team, the GP or the
substance misuse services in Area B.

Phase three- Day 62-Day 77

5.36. On day 62 a local pharmacist called for an ambulance. Josh had not eaten for two days, was homeless
and had injected insulin with the intent of ending his life. The ambulance service submitted a
safeguarding referral due to concerns identified.

5.37. This was followed by continual discharges and admissions throughout this period as depicted in table
one at the start of this section.

5.38. Josh stated that he had been again made homeless as he was thrown out by his landlord. On each
occasion he was treated by medical staff and reviewed by liaison psychiatry. The repeat attender plan
was noted on each admission and was put into action. Josh had various appointments to attend and
support networks in place each time he was discharged.

5.39. On one of these admissions, a safeguarding referral was again suggested by a member of the diabetes
team. On taking advice from senior nurses, this did not progress as it was advised that Josh did not
meet the eligibility criteria for a social worker. The overdoses of insulin were having an increasing
impact with seizures noted by attending ambulance crew. The admission on day 68 led to admission to
High Dependency Unit (HDU).

5.40. On his penultimate admission further contact was made with adult social care who reiterated that Josh
had been seen on a previous admission and that there was no role for social work. Contact was made
with housing services who stated that for emergency housing Josh needed to present as homeless to
Area A between 08.30 and 17.00. On the day of discharge Josh left the ward from 16.00 until 17.20 and
could not be located. When he returned, he was discharged as planned at 17:30.

5.41. The next day at 08.59, Josh was readmitted following seizure activity and reduced conscious level. He
had suffered hypoxic/hypoglycaemia encephalopathy (brain injury resulting from low oxygen and low
blood glucose levels).

6. THEMATIC ANALYSIS

6.1. This section focuses on areas where learning has occurred. Josh presented the greatest risk to himself
by his continual deliberate self-harm by overuse of insulin. It is not his diabetes per se that was an area
where learning can occur. His diabetes gave him the ability to have free access to a prescribed
medication, that when given in larger than required doses, would cause significant harm. Josh knew
this. Josh appeared to be taking large amounts of insulin to gain access to hospital. He stated that he
felt hopeless and helpless about his situation and indicated that he felt that no one was helping him.

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