Page 18 - TSAB Adult B FINAL (1)

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offer an insight into why Josh felt hopeless about his situation. Even when he was housed, there is a
possibility (but there is no assured way of knowing), that the same issues that presented in Area A
began to be repeated in Area B. He talked of being in debt and this is possibly due to his substance
misuse. If he was in debt over rent, it is likely that he was also in debt to drug dealers once again.

6.42. It can be seen why Josh felt that he had no way out and took the decisions that he stated that he
would. What is not clear, and it is not possible to know, is why Josh never overdosed on illicit drugs in
the period under review given his stated intent to die. Any answers to this would be merely
speculation and would not provide any learning for this review.

6.43. Professionals applied the Mental Capacity Act in the best way that they could to support Josh to make
wiser choices at a time that he was not under the influence of substances. Issues of ‘agency and
control’ were not understood by staff because they did not have a clear understanding of Josh as the
whole person. There had been no fully attended multi agency meeting where knowable information
could have been shared and understood by all professionals. This is also discussed in the next section.

Learning Point 7: Understanding lifestyle can support a deeper understanding of
decision making and Mental Capacity.
Learning Point 8: People may not have ‘agency and control’ over their decision making
Learning Point 9: Multi agency working can ensure that all knowable information is
shared and may lead to a better understanding of the impact of substance misuse and
lifestyle on mental capacity and decision making.
Learning Point 10: Commissioning processes can cause difficulties in effective multi
agency working and provision of seamless services

CARE ACT, SAFEGUARDING & SELF NEGLECT

6.44. It is not clear why the hospital social worker did not undertake an assessment of need when a referral
was first sent by the hospital on the second admission. It appears that as Josh had gone to the mental
health inpatient unit that it was assumed that the assessment was no longer needed.

6.45. Safeguarding considerations were discussed on several occasions. Some professionals were of the
belief that as Josh had capacity and was making unwise decisions that there was no role for
safeguarding. It was also stated that as Josh had no need of a care package and was homeless that this
indicated that he was not eligible for safeguarding.

6.46. One safeguarding referral was not progressed by the Local Authority due to Josh being in hospital with
nursing support in place. Another safeguarding referral did lead to a visit on the ward in the acute
hospital, but no assessment was completed as Josh failed to engage. The social worker did some
information gathering and was aware of many of the issues that Josh was facing.

6.47. A Section 42 enquiry was commenced by the Adult Social Care Safeguarding Team using the
information that had been gathered by the hospital social worker from Josh and various professionals.
It was deemed that his needs were being met by all of the agencies that were involved and plans that
were in place from the frequent attender meeting. Both of the referrals were based on a recognition
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