WX was a 66-year old man with serious and persistent health issues. He was suffering from end-stage liver disease as a result of long-term alcohol misuse.
His ex-partner YZ was a 69-year old woman with a history of mental health issues and moderate alcohol misuse. Both WX and YZ were well-known to services.
Although their relationship had ended some years before, WX only wanted YZ to care for him and refused all other care. In 2011, WX chose to stay with YZ and for her to become his primary carer. In 2012, YZ strangled and smothered WX in her home. He died in hospital the next day.
Safeguarding Adults Review
YZ was convicted of manslaughter of WX in 2013. A Domestic Homicide Review was then conducted to ensure that lessons were learnt and practice improved. Although this case pre-dates the introduction of the Care Act 2014, much of the learning from this case remains relevant today.
The review looked at the circumstances of WX and YZ's relationship leading up to his death. The review made recommendations for improvements and learning. Services involved in the review all worked to action plans to implement the recommendations.
Men are at risk of domestic violence too.
Several services raised concerns about the increased tensions between WX and YZ, but gendered assumptions may have prevented services from exploring WX's safety in YZ's care. Also, both WX and YZ were often present when professionals saw them.
- Does your service have a domestic violence policy?
- Are your staff aware of the risks of the so-called 'toxic trio'?
- Do your staff always ensure that they talk to the both the carer and the cared-for person separately?
- Do your staff routinely ask patients, service-users and carers about domestic violence and safety?
Refusal of care is a red flag. WX turned down offers of additional care and instead chose to rely on YZ to meet his increasingly demanding care needs. WX's care would have been challenging for anyone, but even more so for YZ given that she had her own needs and was ambivalent about her wish to be WX's carer. Just because WX had the mental capacity to make decisions about his care, did not mean that it was the right decision for YZ.
- Does your service have guidance for front-line staff on refusal of care and support?
- Do your staff know when and how to escalate concerns about refusal of care?
Robust risk assessment underpins good practice.
Services correctly identified that breakdown of the carer relationship was a risk and that YZ was struggling to cope with WX's needs.
However, the risks were under-estimated and possible mitigations were not explored thoroughly. YZ did not reveal the extent of the difficulties she was having with caring for WX. A more thorough evaluation of the risks would have made the risk assessment more robust.
- Have staff in your service had training on risk assessment?
- Do your staff balance the refusal of formal care against the risk of carer burnout?
The unpaid carer needs to be heard and their needs identified.
The Care Act 2014 requires professionals to consider the unpaid carer's well-being in their own right. The Judge in the criminal trial stated that YZ needed "far more active intervention" and that she "did not reveal the scale of the problem". A more comprehensive carer’s assessment might have been helpful.
- Does your service consider the carer's needs in their own right separately from the needs of the cared-for person?
- Does your service refer unpaid carers for a statutory carer’s assessments?
If you are worried about someone who may be at risk of abuse or harm please contact the Access and Advice Team on 020 7527 2299 or email access.Service@islington.gov.uk.