William Eichler 26 July 2019

Agencies ‘let down’ Down’s Syndrome woman with scabies

A safeguarding report has concluded that local agencies in Hackney ‘could have worked better together’ after the death of a woman with Down's Syndrome.

The 38-year-old woman lived with her mother and had been known to the London Borough of Hackney’s Adult Social Services since March 2007.

She was diagnosed in 2013 with probable crusted scabies and her 2016 support plan stated that she needed help to maintain her personal care. This was provided by her mother.

Hackney council’s Integrated Learning Disabilities Services(ILDS) funded a package of care for six hours per week to support the woman – known as Jo-Jo in the report – to access the community.

In March 2017, Jo-Jo was rushed to an emergency dermatology out-patient appointment after a GP visited the family home. She died in the hospital the same day.

As this was an unexpected death, Barts Health NHS Trust raised a Safeguarding Adults Review referral with the City and Hackney Safeguarding Adults Review Panel and the local Learning Disability Mortality Review (LeDeR) Programme.

The ambulance crew that transported Jo-Jo to the dermatology department also raised a safeguarding referral about her living conditions and deteriorating condition.

A post-mortem concluded that she died of a number of issues including a subarachnoid haemorrhage and ‘severe scabies’, but there was no inquest into the cause of death.

The safeguarding review concluded: ‘a number of different agencies could have worked better together resulting perhaps in avoidance of death, but at least providing a better analysis of pain that Jo-Jo may have been in and possibly seeking clinical engagement sooner.’

Dr Adi Cooper, independent chair of the City and Hackney Safeguarding Adults Board, said: ‘The CHSAB was very sorry to learn of the circumstances surrounding JoJo’s death.

‘There are critical lessons for all agencies involved, to ensure that health and social services for adults with learning disabilities, are improved to minimise the risk of harm, abuse and neglect.

‘A Learning Disability Mortality Review, which looked into the role of health services has been carried out, alongside the SAR to ensure all of the gaps are identified.

‘In addition, all agencies have undertaken individual reviews to identify learning and development, for their own organisation and as part of the wider safeguarding partnership.

‘All of the recommendations are being fully implemented and I hope this review will ensure agencies work better together to ensure no vulnerable adults slip through the net.’

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