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Account to inform an Adult Safeguarding Investigation
Safeguarding adults - If you don’t do something, who will?
Trafford Adult Safeguarding Board
Working in partnership with agencies across Greater Manchester
Confidentiality, distribution, storage and sharing of this document
This document provides an account and is given for the purpose of informing an adult safeguarding investigation, convened under the Trafford
Inter-agency Adult Safeguarding Procedures. This document is shared in strict confidence and its distribution is restricted.
This account relates to the following Adult at Risk:
Name of adult at risk:
NHS/SAP/PPI Number:
Date of Birth:
Sex:
Address:
Post Code:
Telephone number:
Mobile Number:
Ethnicity:
First Language:
Mental Capacity Act, 2005
Female
Did you undertake any formal assessments of capacity
Yes
Male
No
If yes, provide information about each assessment
including: the date completed, decision, the
outcome of each assessment and any best interest
decision
Is the person living or deceased?
Living
Deceased
Coroner’s Inquest?
Yes
No
Not known
Information about the person completing this account:
This account is provided by Any Person.
You should provide information about you, your
qualifications, your role and position within the
team, service or organisation, when you qualified.
You may also include the date you became a
clinician, senior nurse/practitioner or manager if
applicable
I am a Registered Nurse (RN), employed by Anywhere NHS Trust as a
Something Manager/Practitioner.
I am the most senior member of nursing staff on the Something Team/Ward
of the Community Nursing Service/hospital, Anywhere Lane, Anywhere, AN1
ABC.
I qualified as a RN in Any Year.
I have been employed by the Trust since Any Year and was promoted to
Manager in Any Month & Year.
Preparation of this account - what documents, people or records have you used to prepare this report?
I have prepared this account based upon a review of Mr Patient’s nursing records and my own recollection.
I have used my best endeavours to provide an accurate account of those events which I was not personally involved in.
This is my account:
1) On a review of the records, I note Mr Patient had been diabetic for over 15 years and had a diagnosis of Chronic Asthma,
which developed during childhood. Mr Patient had spent much of his adult life in the community. However, there had also
been numerous hospital admissions over the years, including most recently: 8th to 12th April 2011, 21st September to 26th
October 2011 and 2nd to 11th January 2012.
2) Dr X, General Practitioner, reviewed Mr Patient at home on 2nd January 2012. Mr Patient presented with low mood and
reported insomnia, and lack of appetite. He also reported increased breathlessness. His Blood Glucose was recorded as
20mmols, when tested with a BM stick and his peak flow was recorded at 120 and his Sa02 levels were recorded at 79% on
air. He was expectorating copious amounts of sputum. Mr Patient was therefore offered and agreed to admission to Ward XX
of Anywhere Hospital with a provision diagnosis of Chest Infection and unstable Diabetes.
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3) The nursing records show that prior to 2nd January 2012, Mr Patient’s diabetic management had deteriorated considerably
and his Blood Glucose when tested with an HbA1C blood test was found to be significantly outside of the normal range at xx
mmols per litre. Mr. Patient had begun to take a less active role in the self management of his diabetes. Mr Patient was noted
to be withdrawn and was isolating himself from family members, he had begun to neglect his own personal care needs. His
respiratory effort was increasing and his breathing more laboured. His peak flow readings were below his usual range at
xxxxxxx The notes show that throughout our intervention Mr Patient was fully concordant with his care and treatment plans,
which consisted of oral anti-biotics, nebulized inhalations of bronchodilators, steroid therapy, oral hypoglycaemics, antidepressive medications. Despite his concordance and regular clinical review of Mr Patient, his clinical condition continued to
deteriorate and his General Practitioner was requested to visit for a further Clinical Review.
4) On 11th January 2012, I was contacted by XXXXXXXXXXX the Ward Manager on Ward XX at Anywhere Hospital and
advised that Mr Patient told wanted to discharge himself, as he was feeling much better. I was advised that a medical
assessment was conducted on the same day by Dr Y, Senior House Officer. Dr Y agreed that Mr Patient was suitable for
discharge, with follow up in clinic and support from the Community Nursing Team. Dr Y noted in the records that although Mr
Patients mood was low, he denied any suicidal ideation or intention. Mr Patient was discharged on 11th January 2012 with an
outpatient clinic appointment arranged for 21st January 2012. The Community Nursing Team agreed to visit Mr Patient on a
daily basis to support him with education and the monitoring of his blood glucose and administration of insulin, with a view to
self administration in the future.
5) I visited Mr Patient on 12th, 13th, 14th, 15th, 16th and 17th January 2012. On each occasion he was supported to
administer his insulin and monitor his blood glucose. His baseline clinical observations were recorded during each visit and
were within normal range. His respiratory function appeared usual for him and he did not report, when asked, any issues. He
interacted well with me during my visits and said he had become less isolative at home. His mood appeared to have improved
in the days post discharge.
6) On 17th January 2012, I was contacted by telephone by Police Officer X who informed me that Mr Patient has been found
dead at home that day, approximately three hours after my visit.
Declaration and signature:
I declare that the contents of this account are true to the best of my knowledge and belief.
I understand that in certain circumstances it may be necessary to make this account available to my employer, the Care Quality
Commission, professional regulators, the civil, criminal and coroner’s courts, solicitors, local authority officers, NHS officers, police officers
or other professionals involved in the care of the vulnerable adult.
Name:
Signature:
Date:
If this is an electronic document, typing your name will take the place of a “wet” signature
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