Death of 94-year-old woman covered in unexplained injuries sparks East Sussex safeguarding investigation

The woman, known only as Adult B in an anonymised report, died in hospital of natural causes but when admitted had 26 unexplained injuries – including a fractured nose and jaw.

East Sussex County Council says improvements are being made to the way professional support workers ensure the safety of elderly vulnerable people following this case.

This comes after a review by the East Sussex Safeguarding Adults Board (SAB) into the woman’s death in September 2017.

The woman, who also had old and new bruising to her face, arms and legs, was diagnosed with sepsis and pneumonia shortly after her arrival in hospital. She died eight days later.

According to the county council, she had been living with her granddaughter and then with her son and his family.

They were providing most of her day-to-day care but with support from privately-arranged care workers and community nurses.

Following her death, the SAB commissioned a Safeguarding Adults Review to examine the support those professionals had provided and to establish if any lessons could be learnt.

The independent review found that, while professionals had raised and recorded concerns about the unexplained injuries and had questioned the adequacy of the care her relatives were providing, they had only ever spoken to the woman concerned when she was with family members and she insisted she was being cared for properly.

Although the woman had, on occasions, talked about being treated in a way which amounted to physical abuse, including being denied food and drink, and only allowed to use the toilet at certain times, she insisted she did not want it to be investigated as a safeguarding issue or any action to be taken.

She was considered to have the capacity to make that decision, the report said.

The review found professionals should have done more to intervene and concluded agencies working with vulnerable adults who may be subject to coercion and control by their family members needed to be more alert to those risks.

They also needed to be more confident and robust in challenging relatives who might not be providing adequate care, it said.

On the back of the review, the SAB made a number of recommendations for how private care providers, community nurses, GPs, police and adult social care services should improve how they work together.

These included ensuring service users are seen privately and personally away from their families, and better training for professionals working with complex cases especially where there may be coercion or control.

The review also questioned whether the arrangements for investigating adults’ deaths at the time, where abuse or neglect is suspected, were sufficient and asked for options to be scoped that reflected the procedures when a child dies.

Graham Bartlett, the Chair of the SAB said, “The East Sussex Safeguarding Adults Board fully accepts this report and has already established an action plan to ensure its recommendations and findings affect real change.

“This tragic case highlights professionals can be too inclined to assess the needs and vulnerabilities of adults at face value.

“Systems do not always allow them to understand the full historical and current context and, when coupled with a lack of curiosity and a lack of confidence to challenge family members, this can leave vulnerable people at risk.

“This review was concluded in 2019 but, due to the Safeguarding Adults Board referring the matter back to the police for re-investigation, it has not been possible to publish the report until now.

“The outcome of that re-investigation, which was ongoing when the report was completed, is that the threshold for criminal prosecution was not met.

“Through the work that has been progressing in the meantime, the board is confident the learning is being embedded which will makes tragedies like this less likely in the future.”