A long time ago, so the story goes, a Greek philosopher sat out his time in a barrel. His name was Diogenes and the curiosity of his behaviour led to the coining of a syndrome: ‘Diogenes syndrome’. Rarely used nowadays the occasional clinician will make reference to it, sending the rest of the team off to their tablets to find out what is being meant (probably ‘senile squalor’ rather than ultra minimalism).
In social care, terms such as self-neglect, chaotic lives, hard to engage, coerced individuals, and hoarding are more commonly encountered. All present dilemmas in practice of action or inaction, rights or risks, patient safety or patient neglect, urgency or watchful waiting.
Fortunately for practitioners the term self-neglect provides at least some common currency and is now generally used to refer to a person’s unwillingness or inability to care for themselves and/or their living environment. Nonetheless it still encompasses different behaviours, including hoarding, living in squalor or chaos, as well as neglect of oneself.
The Care Act Guidance 2014 recognises self-neglect as a category of abuse and neglect. This means that people who self-neglect may now be supported by safeguarding adult approaches, including Making Safeguarding Personal, as well as receiving more support from practitioners. A recent inexpensive practice guide sets out the key elements of this (Braye, Orr and Preston-Shoot, 2015) while a free overview of research is available from the Social Care Institute for Excellence (Braye, Orr and Preston-Shoot, 2011).
This rather long preamble sets the scene for the article reviewed here. In the context of emerging shared understandings of the myriad of signs of self-neglect the authors explored the findings from 40 serious case reviews (SCR) where self-neglect was described as one of the characteristics of the adult involved or it featured in the context of the harm or risk of harm that led to the SCR.
Their analysis offers important evidence about practice in this area prior to the Care Act 2014 but relates to England (other UK perspectives would be valuable).
Like other analyses of SCRs, including our own on dementia related cases Manthorpe and Martineau, (2014), a set of relevant SCRs had to be compiled.
The authors tracked down published and unpublished summaries or reports – ranging in size from 5 pages to 63 pages. They classified them by noting whether the individual concerned was male or female, their age, their living situation and the circumstances of their death.
In some of these categories this information was not reported. Importantly they also noted whether the self-neglect focus was central to the SCR report, or implicit or even peripheral. The number of recommendations of each SCR is also reported, where available.
So in many ways this is a synthesis based on a patchwork of material and the Care Act’s changes to SCRs, to Safeguarding Adult Reviews (SARs), may promote greater uniformity of reports. It will be interesting indeed to see if the recommendations of SARs are actually any different.
The authors found that of the 32 SCRs examined, almost all (27) recommended training or staff support, while a majority (24) recommended the development, review and dissemination of guidance or procedures, closely followed by procedure being needed for referral and assessment of need and risk (23). These are observations that newly constituted Safeguarding Adults Boards may wish to consider.
In terms of practice, the authors suggest that the SCRs reviewed provide a rich picture of the complexity of practice with adults who self-neglect and illustrate the value of detailed guidance, co-ordinated multi-agency work and decision making, and opportunities for debate and information sharing.
While individual case work may be informed by this, they also highlight the importance of the ‘organisation round the team’ meaning the necessity for supervision and management oversight so that practitioners are supported and decisions agreed then reviewed.
Other observations relate to the conduct of SCRs and possible confusions over their role and conduct. The first set of SARs will help us see if the Care Act has clarified matters or is leading to a more formulaic approach. Similarly, it may be possible by next year to see if the implementation support document being developed by SCIE is helping with difficult decisions about proportionality and priority facing Safeguarding Adults Boards (SCIE, 2015).
The authors conclude that
Overall, these SCRs illustrate the complexity of practice with adults who self-neglect and provide a rich source of learning for those involved in all forms of adult safeguarding. The frequency with which LSABs [Local Safeguarding Adults Boards] have felt it necessary to inquire into the outcome of cases of adults who self-neglect, and to develop procedures in response, coupled with the developing evidence base about effective management and governance of practice in this field, suggests strongly the value of self-neglect being included in statutory guidance on safeguarding to support implementation of the Care Act 2014.
I’ve used SCRs in conversations and practitioner training events for many years. I think they focus on practice and its pushes and pulls. This review of SCRs related to self-neglect suggests this view is shared by others. It will be useful to hear from practitioners if they concur.
The conclusions from this piece of work are that practice scrutiny can and should inform policy and practice development. But, being in summary form, it remains hard to determine why something happened or did not, rather than setting out an apparent linear chain of causation.
New SARs may seek a more forensic approach. Overall the authors indicate that working with people who self-neglect should not be a seen as a discrete area of practice but can inform other parts of safeguarding. For example, there are strong links with relationship building which is, of course, hard to capture in a report. Talking through the letter box to an anxious person, turning up on the doorstep time after time, tracking down past contacts in the hope of a person with ‘access potential’ all take their time and need levels of persistence.
So one important message from this overview of SCRs is that the organisations around the team that is around the individual practitioner need to bear in mind that working with people who self-neglect needs time and skill.
Braye, S., Orr, D., and Preston-Shoot, M. (2015) Learning lessons about self-neglect? An analysis of serious case reviews, Journal of Adult Protection 17 (1) pp.3-18. [Abstract]
Braye, S., Orr D. and Preston-Shoot, M. (2015) Practice Tool: Working with people who self-neglect Totnes: RiPfA [Abstract]
Braye, S., Orr D. and Preston-Shoot, M (2011) SCIE Report 46: Self-neglect and adult safeguarding: findings from research, London, SCIE [Full text]
Manthorpe J and Martineau S (2014) Serious Case Reviews into Dementia Care: An Analysis of Context and Content, British Journal of Social Work first published online November 21, 2014 doi:10.1093/bjsw/bcu135 [Full text]
SCIE (2015) Safeguarding Adults Reviews under the Care Act: implementation support, London, SCIE [Full text]