Ineffective multi-agency working and a service restructuring meant opportunities to intervene were missed in the case of a woman with schizophrenia who died of malnutrition.
Mitchell, who had been known to mental health services since and had alcohol and self-neglect problems, was found dead at her home in September This meant the possibilities of other agencies supporting her under their guidance went unexplored.
Since the Care Act was not in place during the period considered by the review, self-neglect was not included in adult safeguarding arrangements. Her neighbour phoned the police in April worried that he had not heard from her in two days.
They decided to discuss potentially allocating her other support but, the SAR found, there was no evidence as to whether this ever happened. In , another consultant expressed concern at how isolated she was but found that she seemed stable, a perception shared by a number of the doctors who saw her during outpatient appointments. Mental health services made no follow-up visits to her, however, nor was she seen again by them except for one planned appointment in February While police again forced entry to her flat in June after a call from the neighbour, there is no evidence of mental health services being informed.
But it found that the process, which was local authority-led, was poorly understood within the NHS-led mental health partnership, and little used. Meanwhile, more knowledgeable adult care team managers working within the partnership were not responsible for day-to-day case supervision, meaning they were likely to have been out of the loop.
