30/09/2021 Learning From Tragedies

A new Alcohol Change UK report has highlighted that the role of alcohol is being “missed or poorly managed” in the care of vulnerable adults, contributing to their deaths

When vulnerable adults with complex needs also have severe alcohol problems, their drinking is often being missed or poorly managed putting them at further risk of harm, a new report finds. In extreme cases, the failure to properly address the alcohol problem can mean that the other support interventions fail, leading to the person’s death.

The report, published by Alcohol Change UK, analyses all 11 Safeguarding Adult Reviews from England in 2017 in which alcohol was identified as a significant factor in the person’s life and/or death. It charts the stories of people who died in the most tragic of circumstances at a time when they were at their most vulnerable. The report highlights the role that alcohol plays in those situations where vulnerable adults die and draws out essential lessons that may prevent similar tragedies from being repeated.

Although many of these people had dozens or even hundreds of interactions with social workers, paramedics, GPs, police, A&E departments and others, the professional working with them had not received adequate training to identify and address the alcohol elements of the situation. This meant that risks posed by alcohol were missed, under-estimated or poorly managed. In some circumstances, alcohol-dependency and self-neglect were treated as a ‘lifestyle choice’. This led to further barriers in the care of these people – or even the withdrawal of care; and ultimately their deaths.

The reviews tell some tragic stories:

*        Adult A*, was alcohol-dependent and also had multiple long-term health conditions, such as leg ulcers, osteoporosis and diabetes. He moved from the family home and began to self-neglect after his mother and later his father died. He had lost his job and developed mental health and mobility issues. He consistently declined care assessments and help. In June 2013, his GP referred him to Environmental Health due to his unhygienic and unsafe living conditions. His informal carer was also drinking and was suspected to be financially exploiting him. However, Adult D’s mental capacity was never formally assessed. It was suggested in the review that this could have been due to his prior professional standing and ability to articulate himself well, which may have led practitioners inaccurately to assume that his mental capacity was good, despite rarely being in a stable mental state due to his drinking. He died in hospital of sepsis and multiple organ failure.

*        Adult B*, was alcohol-dependent. His drinking caused him to lose his job and tenancy in 2014, at which point he moved to supported housing. There he lived alone and had no contact with his family. In Spring 2015, his close friend and fellow housing resident died suddenly, which led to a rapid decline in Andrew’s emotional well-being and he began to self-neglect. Andrew had a long-standing relationship with a drug and alcohol worker who was starting to intervene, but the service was decommissioned in 2016 and the worker was no longer assigned to Andrew’s case. Andrew died of alcohol-related illnesses shortly afterwards, aged 39.

  •        Adult C*, was unemployed due to ill-health from his alcohol-dependence and a leg fracture which did not heal properly. He had been estranged from his family as they found his alcohol use too challenging to manage. RN died aged 48 due to chronic self-neglect and refusing help. His body was not found for 15 days after his death, due to his history of not engaging with social care professionals, and those professionals mistakenly treating his disengagement and alcohol use as his own free choice.

The report makes ten key recommendations, including:

  *  Recommendation 2: A person’s refusal of care from services needs to be constantly challenged. New and creative ways need to be used to encourage vulnerable people to address their alcohol problem. The refusal of alcohol treatment should not lead to anyone being “written off” as being beyond help. In particular, alcohol treatment services may need to adapt their models in order to better serve these adults, for example through home visits.

  *  Recommendation 3: All professionals working with alcohol-dependent adults should be trained to recognise the complicated role that alcohol plays in adult safeguarding. Social workers, GPs, paramedics, police and others should not automatically be expected to be experts on alcohol problems and must instead be provided with high-quality training. In particular, training should help these professionals to challenge the common misconception that alcohol misuse is necessarily a ‘personal choice’ that must be respected.

  *  Recommendations 7, 8, 9 and 10: Professionals working with vulnerable adults need further legal backing, guidance and training to help them more effectively intervene, strengthening current legislation. This will enable professionals to use legal powers to mandate alcohol-related interventions where they are in the best interests of the vulnerable person.

The recent passing of the Mental Capacity (Amendment) Act 2019 is a golden opportunity for change. To help minimise alcohol-related self-neglect, it is crucial that the revised Code of Practice, which comes into force alongside the Act in Spring 2020, includes specific guidance on how to apply the legislation to alcohol-related cases to ensure vulnerable adults, who lack capacity to make specific decisions in relation to their care needs, are much better protected.

Dr Richard Piper, Chief Executive of Alcohol Change UK, said:

“Our report reveals the tragic stories of lives lost in some of the most terrible of circumstances. We as a society owe it to the memories of the people who have died and their families to make the most of the learning from this review to prevent such tragedies in future.

“The recommendations that we offer are workable and urgent, especially for those people who are alive today and are at risk of being the subject of a future Safeguarding Adult Review. Most importantly, professionals who are working hard in the most difficult of circumstances need to receive proper legal backing and much better training in how to handle the genuine complexities of an alcohol problem when it is entwined with other challenging issues.”

The full report ‘Learning from tragedies: an analysis of alcohol-related Safeguarding Adult Reviews’ is available at:

Resourced: Alcohol Change UK

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