Yahoo News Woman later died after 'inappropriately' discharged son with mental health issues attacked her
A Stockton woman died 18 days after a serious assault carried out by her own son.
The death of the woman, known only as ‘Susan’, in August last year, was attributed to natural causes. However a Safeguarding Adults Review (SAR) said she had been seriously harmed, both physically - suffering significant facial injuries - and emotionally.
Her son, who had subjected his mother to a previous attack, was receiving treatment from a mental health trust psychosis team for a schizo-affective disorder. But only weeks earlier he’d been discharged back into the care of his GP with an overview report associated with the SAR stating no current or specific ongoing risks to the family had been identified with the impression being given the son was well.
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He was arrested and detained under the Mental Health Act after it was realised he had been suffering from a psychotic episode. A migrated record which led to information about previous issues not being seen on a social care system was one reason given for the situation being regarded as less critical than it was.
The report said: "It cannot be known whether if Susan’s son had not been inappropriately discharged or follow up had been more assertive, the assault could have been prevented, but there may have been opportunities to assess his mental health more readily."
After a referral from a social worker the SAR was commissioned by the Teeswide Adult Safeguarding Board (TSAB), a statutory body which co-ordinates and ensures the effectiveness of work to safeguard adults living in Teesside.
The 58-year-old victim was a wheelchair user, having previously suffered a stroke which left her with physical disabilities and communication difficulties, who was supported at home by her own mother and family members, including her son.
The report said the son was affected by the death of his grandmother - Susan’s mother - three months previously and stopped taking his medication, which had allowed his illness to be managed, and had also missed appointments. He was described as having no recollection of events and did not participate in the review that took place.
The report described how Susan, a former shop worker, had been assaulted by her son two years prior to the scoping period for the review.
A safeguarding case was opened at the time by the local council after a notification from the police, but it was recorded that the criteria for a formal safeguarding enquiry had not been met. The case was closed as it was deemed that the risk had been removed with the son again being detained under the Mental Health Act.
Susan’s mother had also been clear that it was an isolated occurrence and out of character, and the family did not require any help and support. A week before the 2023 incident another family member called adult social care services concerned that Susan’s mother had passed away and, given her circumstances, a referral was made for a care assessment.
‘Difficult family dynamics’
The review said that the “difficult family dynamics” were discussed, including the fact that Susan was living with a son who had mental health issues and may not be taking his medication.
However focus was placed on a faulty stair lift and Susan’s general care and support needs, rather than concerns specifically about any risk from the son. The care assessment was also placed on a holding list, suggesting no identified risk or urgency was required.
Following the second assault, Susan was “completely devastated and shocked” and stated she did not wish to live with her son any longer. She also agreed to have an emergency ‘pendant call’ button fitted and be supported by a safety plan.
However in the days that followed she became unwell with a diarrhoea and vomiting bug with any visits to her being cancelled and she had also suffered a fall, which caused pain in her foot. She was admitted to hospital with tests identifying a blood clot in her leg and was also diagnosed with an acute kidney injury.
Susan died four days later, despite receiving treatment, with the police, on behalf of the coroner, subsequently investigating the cause of death and deciding that it was not related to the recent assault by Susan’s son, but due to other natural causes.
The review concluded that professionals had responded immediately to the 2023 incident with a formal safeguarding enquiry being launched. Meanwhile, the mental health trust reviewed the issues that had been raised for them after concluding the son’s discharge back to his GP had not been appropriate and had put together an “extensive action plan” in order to make changes.
The review said some services involved in the case were not aware of the “safety net” that the grandmother provided. It also said that rather than relying on information from Susan’s mother alone via the telephone, which had occurred, best practice would have been to visit the household to ensure there was agreement between mother and daughter about what support was needed.
The review said agencies needed to ensure that safeguarding concerns were shared appropriately and flagged on systems to ensure that future risks were assessed more readily and accurately. Adrian Green, independent chairman of the TSAB, said: “This is a sad and complex case - our thoughts and condolences are with Susan’s family and friends.
“This Safeguarding Adults Review has recognised areas of good practice by staff, but it has also identified several areas where improved partnership working, including better sharing of safeguarding concerns and flagging on systems where possible will help agencies identify future risks and prevent incidents like the one involving Susan from happening to others.
“It is of the utmost importance for agencies to be professionally curious to better understand how and if families are managing with difficulties and what extra support they may need. These findings and recommendations have already been shared with the relevant organisations and I am confident they will help deliver better decision making and improved support for those at risk.”
Councillor Pauline Beall, the cabinet member for social care at Stockton Council, added: “The council has addressed the report’s recommendations to assure that safeguarding warning flags or alerts are visible when migrating electronic records to new systems. All agencies must also ensure that mental health issues are fully explored to understand any risks, to make sure we are doing everything we can to help protect vulnerable adults from harm.”
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