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Self-Neglect

<p>The Safeguarding Adults Board has developed local guidance to support safeguarding where self-neglect and/or hoarding is a factor. It should be read alongside this section of the procedure.</p>
<p>Further information on hoarding can be found in the <a href="/resources/contacts-and-practice-resources?root=b210981d-17db-4923-9cf6-86b4f10a4f8a">Contacts and Practice Resources</a>&nbsp;section.</p>
<p>Additional guidance is available on the <a href="https://www.centralbedfordshire.gov.uk/info/147/private_renting_enforcement/967/help_a_hoarder_in_private_rented_housing#:~:text=Email%20psh%40centralbedfordshire.gov.,cleaning%20company%20and%20family%20members." target="_blank" rel="noopener">Central Bedfordshire Council website, Help a hoarder in private rented housing</a>.</p>

Local Guidance

<p>Self-neglect can broadly be defined as one or more of the following:</p>
<table title="self-neglect defined">
<tbody>
<tr>
<td><strong>Lack of self-care</strong></td>
<td>This includes neglect of personal hygiene, nutrition and hydration, or health, to an extent that may endanger safety or wellbeing.</td>
</tr>
<tr>
<td><strong>Lack of environment care</strong></td>
<td>This includes situations that may lead to domestic squalor or elevated levels of risk in the domestic environment (e.g., health or fire risks caused by <a href="/chapter/hoarding">hoarding</a>).</td>
</tr>
<tr>
<td><strong>Refusal of assistance to alleviate issues</strong></td>
<td>This might include, for example, refusal of care services in either their home or a care environment or of health assessments or interventions, even if previously agreed, which could potentially improve self-care or the home environment.</td>
</tr>
</tbody>
</table>

What is Self-neglect?

<p>Self-neglect can be a result of a range of factors and understanding the fundamental causes is essential for addressing the concerns effectively. Some causes of Self-Neglect can include:</p>
<ul>
<li><strong>Mental health</strong> issues such as depression, anxiety or diagnosed schizophrenia and psychosis;</li>
<li><strong>Cognitive impairments</strong> such as dementia, intellectual disabilities, or traumatic brain injury;</li>
<li><strong>Physical health</strong> issues such as chronic illness; mobility issues or substance misuse;</li>
<li><strong>Social isolation</strong>; or</li>
<li><strong>Trauma</strong>.</li>
</ul>
<p>Self-neglect may be intentional or unintentional, brief or prolonged, and can occur as repeated or isolated incidents.</p>

Causes of self-neglect

<p>Given the complex and diverse nature of self-neglect, responses by a range of organisations are likely to be more effective than a single agency response with reference to housing providers.</p>
<p>It is important to recognise that assessments of self-neglect are grounded in, and influenced by, personal, social, and cultural values and people working with the adult should always reflect on how their own values might affect their judgement.</p>
<p>Finding the right balance between respecting the adult's autonomy and meeting the duty to protect their wellbeing can be challenging. It may involve building up a rapport with the adult to come to a better understanding about whether self-neglect are matters for adult safeguarding or any other kind of intervention.</p>
<p>As there are many causes of self-neglect, it is helpful to try and determine when the self-neglect began as this can help explain why it is happening.</p>
<p>Self-neglect should not be seen simply as a lifestyle choice or the way someone prefers to live. Professionals still have a duty of care to understand why those decisions are being made and explore how to support someone who is self-neglecting and unwilling to engage with help. This involves building a relationship with the person and requires multi-agency collaboration, rather than decisions being made by a single individual or service.</p>
<p>If a person self-neglects because they are unable to care for themselves due to, for example a physical disability, then the most appropriate course of action may be a full assessment of needs and a care and support plan.</p>
<p>Some people self-neglect because of trauma, loss, or bereavement. A person may have been neglected or abused, may be experiencing domestic abuse, or may have had significant loss in their life. This trauma or loss may have affected their self-esteem, self-worth, and ability to self-care. Support from mental health services or a full needs assessment may be helpful to consider all aspects of the person's wellbeing.</p>
<p>It is important to ensure that the adult is not being abused, coerced or harassed into making decisions resulting in self-neglect. There could be a range of reasons why someone can self-neglect, it is important not to make assumptions. Professional Curiosity is particularly helpful in these situations. See <a href="/chapter/professional-curiosity">Professional Curiosity</a>.</p>

Responding to Self-neglect and Hoarding

<p>Crucial to all decision making is a robust risk assessment, preferably multi-agency that includes the views of the adult and their informal networks of support.</p>
<p>The risk assessment might cover:</p>
<ol style="list-style-type: lower-alpha;">
<li>Capacity and consent;</li>
<li>Indications of mental health issues;</li>
<li>The level of risk to the persons physical health;</li>
<li>The level of risk to their overall wellbeing;</li>
<li>Effects on other people's health and wellbeing;</li>
<li>Serious risk of fire;</li>
<li>Serious environmental risk e.g. destruction or partial destruction of accommodation.</li>
</ol>
<p>The&nbsp;Clutter Image Ratings (CIR) may also be a helpful decision-making tool. It is a rising pictorial scale of nine photographs showing clutter in three rooms &ndash; living room, bedroom and kitchen. See <a href="https://hoardingdisordersuk.org/research-and-resources/clutter-image-ratings/" target="_blank" rel="noopener">Clutter Image Ratings (CIR)</a>.</p>

Risk Assessment

<p>If the adult has a carer, it is important to consider their ability to meet the needs of the adult and rule out any neglect or acts of omission. It could be that the carer has unintentionally neglected the caring role because they are no longer able to cope.</p>
<p>Carers can also neglect themselves due to the stresses and demands of their caring responsibilities. It is important to consider whether a carers assessment may be required. Under the Care Act 2014 a carer is eligible for an assessment of their needs regardless of how many hours a week they provide care. See: <a href="https://careact.trixonline.co.uk/chapter/legal-requirements-of-a-carers-assessment" target="_blank" rel="noopener">Legal Requirement of a Carers Assessment</a>.</p>

Carers

<p>The Environmental Health Service (EHS) has a range of powers to intervene where a property is in a condition that is prejudicial to health, or where the premise is materially affecting neighbouring premises.</p>
<p>In addition, where properties are verminous or pose a statutory nuisance, the EHS will take a leading role in case managing the necessary investigations and determining the most effective means of intervention.</p>
<p>Where the adult is residing in conditions that pose a threat only to their own welfare the powers available to the EHS may have limited or no effect.</p>

Environment Health Service Intervention

<p>Self-neglect becomes a safeguarding issue when an adult is at risk of significant harm or there is a risk of harm to their health, safety, or wellbeing due to their inability or unwillingness to care for themselves.</p>
<p>An update to the Care Act statutory guidance in March 2016 gave detail as to when self-neglect should be considered safeguarding:</p>
<p><em>"It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case-by-case basis. A decision on whether a response is required under safeguarding will depend on the adult's ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support."</em></p>
<p>Signs that Self-Neglect may be a safeguarding concern are:</p>
<ol style="list-style-type: lower-alpha;">
<li>When it is apparent that a person has poor personal hygiene, such as unkempt appearance, body odour and/or wearing unwashed clothing consistently;</li>
<li>Where there is a decline in health because of non-engagement with essential treatment, for example declining medication, refusing pressure ulcer treatment;</li>
<li>Their living environment is unclean, such as accumulation of rubbish, clutter, dirt or signs of pests or insects, which may also lead to fire risk or risk to others;</li>
<li>Unsafe living conditions to include a lack of running water, heat and or electricity;</li>
<li>Evidence of malnutrition or dehydration, lack of food in the home and weight loss.</li>
</ol>

When is Self-neglect a Safeguarding Issue?

<p>The National Network of Safeguarding Adults Boards (NNSAB) website provides lots of useful information about safeguarding, including sharing best practice. The following is a list of common themes from Safeguarding Adult Reviews of deaths due to self-neglect: &nbsp;</p>
<ol style="list-style-type: lower-alpha;">
<li>Refusal of help;</li>
<li>Inadequate or delayed risk assessments;</li>
<li>Lack of Multi-Agency Coordination;</li>
<li>Failure to Escalate Concerns.</li>
</ol>

Summary of Deaths from Safeguarding Adult Reviews (SARs)

<p>The purpose of SARs is outlined in the statutory guidance as to &lsquo;promote effective learning and improvement action to prevent future deaths or serious harm occurring again&rsquo;.</p>
<p>Some identified areas of improvement for services in relation to self-neglect are:</p>
<ol style="list-style-type: lower-alpha;">
<li>Earlier, coordinated risk assessments;</li>
<li>Enhanced multi-agency collaboration;</li>
<li>Better use of mental health resources:</li>
<li>Proactive escalation of concerns;</li>
<li>Involvement of advocacy services.</li>
</ol>
<p>For further information see: <a href="https://nationalnetwork.org.uk/about_us.html" target="_blank" rel="noopener">National Network for Chairs of Adult Safeguarding Boards</a>.</p>

Learning from SARs

Radicalisation and Violent Extremism

<p>Since the publication of the HM Government Prevent Strategy in 2011, there has been an awareness of the specific need to safeguard vulnerable individuals (adults, children and families) from the risk of radicalisation and violent extremism. This is a safeguarding matter and should be approached in the same way as other risks.</p>
<h3>Definitions</h3>
<p>Radicalisation is the process by which people come to support terrorism and extremism and, in some cases, to then participate in terrorist activity.</p>
<p>Extremism is defined in the Prevent Strategy as &ldquo;vocal or active opposition to fundamental British values, including democracy, the rule of law, individual liberty and mutual respect and tolerance of different faiths and beliefs. We also include in our definition of extremism calls for the death of members of our armed forces, whether in this country or overseas".</p>

Introduction and Definitions

<p>Radicalisation is a process rather than an event, and there is no single profile or pathway by which an individual can be drawn into violence or exposed to extremist messages. Some people may be influenced by family members or friends and/or direct contact with extremist groups or organisations. Others may view online content, in particular social media, that can normalise radical views or promote violent extremism.</p>
<p>In all cases, professionals should ensure that judgements consider individual circumstances and place the behaviour of an individual in their whole family and social context.</p>

Vulnerabilities and Indicators

<p>There are many factors which, either alone or combined with other vulnerabilities, can increase an individual&rsquo;s risk of being radicalised.</p>
<p>These can include, but are not limited to:</p>
<ul>
<li>Identity Crisis - Distance from cultural / religious heritage and uncomfortable with their place in the society around them;</li>
<li>Personal Crisis - Family tensions; sense of isolation; low self-esteem; disassociating from existing friendship group and becoming involved with a new and different group of friends; searching for answers to questions about identity, faith and belonging;</li>
<li>Personal Circumstances - Migration; local community tensions; events affecting country or region of origin; alienation from UK values; having a sense of grievance that is triggered by personal experience of racism or discrimination or aspects of Government policy; experience of care (previous looked after child);</li>
<li>Unmet aspirations - Perceptions of injustice; feeling of failure; rejection of community values;</li>
<li>Criminality - Experiences of imprisonment; previous involvement with criminal groups;</li>
<li>Neurodiversity - Individuals who are neurodiverse may experience difficulties developing friendships / relationships; they can often be skilled in using technology and may develop online friendships / networks; they may be more likely to accept information they are accessing without questioning it.</li>
</ul>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>There is a correlation between online risk and real-life vulnerability that means that there could be an increased risk of encountering online harm. Individuals with prior off-line vulnerabilities are at greater risk of harm online than those with none.</p>
</div>
</div>

Vulnerabilities

<p>Indicators that an individual may be experiencing, or at risk of radicalisation can include, but are not limited to:</p>
<ol style="list-style-type: lower-alpha;">
<li>General changes of mood, patterns of behaviour, secrecy;</li>
<li>Changes of friends and mode of dress;</li>
<li>Spending an increased amount of time online;</li>
<li>Use of inappropriate language;</li>
<li>Possession of violent extremist literature;</li>
<li>The expression of extremist views;</li>
<li>Planning to take long term holidays and visits out of the UK;</li>
<li>Advocating violent actions and means;</li>
<li>Association with known extremists;</li>
<li>Seeking to recruit others to an extremist ideology.</li>
</ol>
<p><strong>Note</strong>: There is an obvious difference between espousing radical and extreme views and acting on them. Holding radical or extreme views is not illegal &ndash; what is illegal is the act of committing an offence or inciting others to do so in the name of that belief or view.</p>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>A common feature of radicalisation is that the individual often does not recognise the exploitative nature of what is happening and does not see themselves as a victim.</p>
</div>
</div>

Indicators

<p>If someone is at immediate risk of harm due to radicalisation or violent extremism, or if you believe that a terrorist act is being committed or planned, alert the police using 999.</p>
<p>If this is not the case, a police referral should be made under the Prevent duty (see below).</p>
<p>If the threshold for raising a safeguarding concern has been met, a concern should also be raised to the local authority in line with safeguarding adult procedures.</p>
<p>For further information, see:&nbsp;<a href="disclosure-and-raising-a-concern">Disclosure and Raising a Concern</a>.</p>
<p>Upon receiving the concern, if the police are not already aware, the local authority should make a referral under the Prevent duty (see below). This will ensure that the police can evaluate the need for any police action to reduce the risk from potential terrorist activity.</p>
<p>Once any immediate risk of harm has been removed or adequately reduced, appropriate and proportionate subsequent action should be agreed by relevant agencies. For example, escalation to a Police-led partnership, an enquiry under Section 42 of the Care Act, or a Channel Panel process (see below).</p>
<p><strong>Note:</strong> Safeguarding people from radicalisation and extremism requires careful assessment and collaborative working across agencies. Initial information may be inconclusive, and the most appropriate action can be dependent on a wider range of factors.</p>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>Online material which promotes extremism, such as illegal or harmful videos and images, can be reported online to the government.</p>
<p>See: <a href="https://www.gov.uk/report-terrorism" target="_blank" rel="noopener">Report online material promoting terrorism of extremism</a>.</p>
</div>
</div>

Safeguarding Response

Prevent, the Prevent Duty and Channel

<p>&lsquo;Prevent&rsquo; is one of the four pillars of the UK government&rsquo;s counter terrorism strategy, CONTEST.</p>
<ul>
<li>Prevent &ndash; to stop people becoming terrorists or supporting terrorism;</li>
<li>Pursue &ndash; to strengthen our protection against a terrorism attack;</li>
<li>Protect &ndash; to strengthen our protection against a terrorism attack; and</li>
<li>Prepare &ndash; to mitigate the impact of a terrorist attack.</li>
</ul>
<p>&lsquo;Prevent&rsquo; has three main objectives:</p>
<ol>
<li>Tackle the ideological causes of terrorism;</li>
<li>Intervene early to support people susceptible to radicalisation;</li>
<li>Enable individuals who have already engaged in terrorism to disengage and rehabilitate.</li>
</ol>

Prevent

<p>Under Section 26 of the Counter-Terrorism and Security Act 2015, specified authorities must, in the exercise of their normal functions, have due regard to the need to prevent individuals of any age from being drawn into terrorism. This includes becoming a terrorist or supporting terrorism. This is the Prevent duty.</p>
<p>The aim of the Prevent duty is to stop individuals from becoming terrorists or supporting terrorism. Supporting individuals already involved in terrorism to disengage and rehabilitate is also part of the duty. The duty helps to ensure that individuals who are susceptible to radicalisation are supported as they would be under existing safeguarding processes.</p>
<p>The specified authorities to whom the Prevent duty applies are:</p>
<ul>
<li>Local authorities;</li>
<li>Education;</li>
<li>Healthcare;</li>
<li>Police;</li>
<li>Criminal justice agencies (prisons and probation).</li>
</ul>
<p>There is statutory guidance that sets out the expectations for each specified authority and the ways in which it should comply with the Prevent duty.</p>
<p>See:&nbsp;<a href="https://www.gov.uk/government/publications/prevent-duty-guidance" target="_blank" rel="noopener">Prevent duty guidance: for England and Wales</a>.</p>
<p>Where an individual is identified as being susceptible to radicalisation, a Prevent referral should be made to the police. These referrals should be made in line with local processes and requirements.</p>
<p>The police will evaluate the referral and, if there are reasonable grounds to suspect the individual is at risk of radicalisation, make a further referral to the local Channel Panel (see below).</p>
<p>If the risk is serious or imminent, the police may decide that a Channel Panel approach would not be appropriate. Neither should a Channel Panel referral be made after radicalisation has occurred.</p>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>The government has also developed non-statutory guidance for healthcare professionals.</p>
<p>See: <a href="https://www.gov.uk/government/publications/prevent-duty-guidance-for-healthcare-professionals" target="_blank" rel="noopener">Prevent duty: guidance for healthcare professionals</a>.&nbsp;</p>
</div>
</div>

The Prevent Duty

<p>Under Section 36 of the Counter-Terrorism and Security Act 2015, as part of the UK Government&rsquo;s prevent strategy, each local authority has a duty to ensure there is a local Channel Panel in place.</p>
<p>The Channel Panel is a multi-agency panel chaired by the local authority that must include the police and other relevant local partner agencies. It can be a single area panel or a combined panel with other local authorities.</p>
<p>The role of the Panel is to intervene as early as possible to ensure that people of any faith, ethnicity or background who are at risk of radicalisation receive support before their vulnerabilities are exploited by those that would want them to embrace terrorism, and before they become involved in criminal terrorist activity.</p>
<p>The following are a few examples of possible support responses:</p>
<ul>
<li>Faith guidance;</li>
<li>Counselling;</li>
<li>Diversionary activities;</li>
<li>Access to specific services, such as health or education.</li>
</ul>
<p>Wherever possible the response should be appropriately and proportionately provided from within the normal range of universal provision available from local agencies and partners.</p>
<p>Each agency is responsible for implementing the actions allocated to them.</p>
<p>The effectiveness of the response should be regularly reviewed and updated as required should the risk level change.</p>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>In carrying out their role, the Channel Panel must have regard to the <a href="https://www.gov.uk/government/publications/channel-and-prevent-multi-agency-panel-pmap-guidance" target="_blank" rel="noopener">Channel Duty Guidance: Protecting people susceptible to radicalisation</a>.</p>
</div>
</div>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>The Channel process is a voluntary process. If an individual is over the age of 18, it can only take place if they consent (or in their best interests if they lack capacity to consent). Where the individual is under 18, consent must be sought from a parent or legal guardian. In all cases, if consent is not obtained within 3 months of the Channel process starting, the case must close and alternative options to safeguard the adult explored (for example, this could be escalation to a Police-led partnership or a health/social care intervention).</p>
</div>
</div>

Channel Panel

<p>All professionals and staff who engage with the public should:</p>
<ul>
<li>Understand what radicalisation means and why individuals may be vulnerable to being drawn into terrorism as a consequence of it;</li>
<li>Be aware of what the government means by the term 'extremism' and the relationship between extremism and terrorism;</li>
<li>Know what measures are available to prevent individuals from becoming drawn into terrorism and how to challenge the extremist ideology that can be associated with it;</li>
<li>Understand how to obtain support for individuals who may be being exploited by radicalising influences.</li>
</ul>
<p>There is a range of free, online training available on the government website. This includes an awareness course, Prevent referrals course and a Channel course.</p>
<p>For further information, or to access the training courses see:&nbsp;<a href="https://www.gov.uk/guidance/prevent-duty-training" target="_blank" rel="noopener">Prevent duty training</a>.</p>
<p><strong>Note:</strong>&nbsp;The Home Office can provide additional training to Channel Panel Chairs, Deputy Chairs and Panel members.</p>
<div class="panel panel-info">
<div class="panel-heading">Need to know</div>
<div class="panel-body">
<p>NHS staff should also use the NHS Prevent training and competencies framework.</p>
</div>
</div>

Training and Awareness

<p><a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/97976/prevent-strategy-review.pdf" target="_blank" rel="noopener">Prevent Strategy</a></p>
<p><a href="https://www.gov.uk/government/publications/prevent-duty-guidance" target="_blank" rel="noopener">Prevent Duty Guidance: for England and Wales</a></p>
<p><a href="https://www.gov.uk/government/publications/prevent-duty-guidance-for-healthcare-professionals" target="_blank" rel="noopener">Prevent Duty: Guidance for healthcare professionals</a></p>
<p><a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/964228/6.6271_HO_HMG_Channel_Duty_Guidance_v13_WEB_Engish.pdf" target="_blank" rel="noopener">Channel Duty Guidance: Protecting people susceptible to radicalisation</a></p>
<p><a href="https://www.gov.uk/government/publications/prevent-duty-self-assessment-tool-further-education" target="_blank" rel="noopener">Guidance - Prevent Duty Self-assessment Tool: Further Education - self-assessment tool to assist colleges and providers in the further education and skills (FE) sector in England to review their Prevent responsibilities</a></p>
<p><a href="https://actearly.uk/spot-the-signs-of-radicalisation/what-to-look-for/" target="_blank" rel="noopener">Act Early for Signs of Radicalisation - What to Look For</a></p>

Further Information and Guidance

Fabricated or Induced Illness in Adults

<p>This guidance will support practitioners in all partner organisations to understand and respond to suspected fabricated and induced illness in adults.</p>
<p>Fabricated or induced illness is most commonly associated with children. However, there are increasing numbers of incidents involving adults with and without capacity, and younger adults going through the transition into adulthood.</p>
<p>Fabricated or induced illness is not always a safeguarding concern, but it can be when:</p>
<ul>
<li>Another person has intentionally (or unintentionally) induced the illness;</li>
<li>Another person has used coercive or controlling behaviour to force the adult to fabricate or induce the illness (psychological or domestic abuse);</li>
<li>Another person is fabricating an illness in themselves for the purpose of coercing or controlling the adult (psychological or domestic abuse);</li>
<li>The illness has been induced because the adult is neglecting their own needs (self-neglect).</li>
</ul>
<h3>Fabricated illness</h3>
<p>This involves an adult pretending to be ill when they are not ill at all. For example, claiming to hear voices or have chest pain.</p>
<h3>Induced illness</h3>
<p>This involves an adult doing something to themselves to cause (or induce) illness. For example, rubbing dirt into a wound to cause an infection or drinking a harmful substance to bring about vomiting.</p>
<h3>Fabricated or induced illness by proxy</h3>
<p>Fabricated or induced illness by proxy occurs when the presenting illness has been fabricated (made up) or induced (caused) by a third party. This may be a carer, friend, family member or professional. It could also be multiple people coordinating the fabrication or inducement of illness (for example several family members or professionals working together).</p>
<p>The following are the main (but not all) the ways in which an illness in an adult can be fabricated or induced by proxy:</p>
<ul>
<li>Fabrication of signs and symptoms;</li>
<li>Fabrication of past medical history;</li>
<li>Falsification of hospital charts, records, letters and documents and specimens e.g., bodily fluids;</li>
<li>Exaggeration of symptoms/real problems;</li>
<li>Inducing illness by a variety of means such as overuse of medication, causing injuries, withholding food etc.</li>
</ul>
<p>Failing to identify a case of fabricated or induced illness by proxy can lead to harmful or unnecessary medical interventions being carried out, based upon symptoms that have been falsely described, fabricated or induced.</p>

Causes of Fabricated or Induced Illness in Adults

<p>There are many reasons why an adult may present with a fabricated or induced illness, and it is important to use professional curiosity to investigate all potential causes and ensure the most appropriate and proportionate response.</p>
<p>See: <a href="/chapter/professional-curiosity">Professional Curiosity</a>.&nbsp;</p>

Professional curiosity

<p>Self-harm is when someone intentionally damages or injures their body.</p>
<p>Types of self-harm may include, but are not limited to:</p>
<ul>
<li>Cutting the skin;</li>
<li>Burning the skin;</li>
<li>Punching the body;</li>
<li>Poisoning;</li>
<li>Misusing alcohol or drugs (including not taking prescribed medication);</li>
<li>Not engaging with or sabotaging treatment to improve a condition;</li>
<li>Eating disorders.</li>
</ul>
<p>Some of the reasons that adults may self-harm include, but are not limited to:</p>
<ul>
<li>Expressing or coping with emotional distress (trauma);</li>
<li>Trying to feel in control;</li>
<li>A way of punishing themselves;</li>
<li>Relieving unbearable tension;</li>
<li>A cry for help;</li>
<li>A response to intrusive thoughts;</li>
<li>A desire for attention from others.</li>
</ul>
<p>Self-harm should always be considered as the possible cause of an induced illness and, where self-harm is a factor, a trauma informed approach should be taken, and adults supported to access appropriate support from mental health services.</p>
<p>For further information and guidance about identifying and treating self-harm, see:&nbsp;<a href="https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/self-harm/" target="_blank" rel="noopener">Self-harm</a>.</p>

Self – harm

<p>Fabricated or induced illness may be a sign of abuse or neglect, particularly when the adult has numerous unexplained injuries (sprains, bruises, lacerations etc.), or their presenting symptoms indicate:</p>
<ul>
<li>Overdose, misuse or omission of prescribed/unprescribed medication;</li>
<li>Neglect/omission of basic needs (hydration, nutrition);</li>
<li>Neglect/omission of care and support needs (e.g., continence care, oral care);</li>
<li>Self-neglect of basic or care and support needs by the adult themselves.</li>
</ul>
<p>Where fabricated or induced illness presents, consideration should be given to whether:</p>
<ul>
<li>Another person has intentionally (or unintentionally) induced the illness (fabricated or induced illness by proxy);</li>
<li>Another person has used coercive or controlling behaviour to force the adult to fabricate or induce the illness (psychological or domestic abuse);</li>
<li>Another person is fabricating an illness in themselves for the purpose of coercing or controlling the adult (psychological or domestic abuse);</li>
<li>The illness has been induced because the adult is neglecting their own needs (self-neglect).</li>
</ul>
<p>If any of the above apply (or may apply), and the adult has (or appears to have) a need for care and support, the safeguarding duty may apply.</p>
<p>For further information, see&nbsp;<a href="#raising-a-concern-and-the-safeguarding-response">Section 4, Safeguarding Response</a>.</p>

Abuse or neglect

<p>If there is no evidence to suggest self-harm or abuse or neglect, other causes and motivators should be considered. There will always be a reason that the adult (or other person) is fabricating or inducing the illness.</p>
<p>Examples of other causes are:</p>
<ul>
<li>To expediate access a social care, health or other service;</li>
<li>Homelessness and housing issues;</li>
<li>Poverty (being in hospital ensures warmth and a meal);</li>
<li>Social isolation (being in hospital combats loneliness);</li>
<li>Fraud (for example, to claim benefits).</li>
</ul>
<p>In many cases, supporting the adult to address their primary concern can prevent further occurrences of fabricated or induced illness.</p>
<h4>Munchausen syndrome&nbsp;</h4>
<p>The cause of the fabricated or induced illness is unlikely to be Munchausen syndrome. As such, it should only be considered as a possible cause when all other causes have been ruled out. Munchausen syndrome is a very rare psychological condition where the main intention of the adult is to fabricate or induce illness in themselves so that people care for them and/or they are the centre of attention.</p>

Other causes

<p><strong>Note</strong>: Even if fabricated or induced illness is suspected, access to medical treatment (including emergency treatment) should never be delayed.</p>
<p>This is an incredibly complex and challenging area of practice. The indicators in this section should act as triggers for further investigation and do not on their own confirm that an illness is fabricated or induced.</p>
<ul>
<li>All the circumstances of the case and evidence from the full range of available sources should be carefully considered by an appropriate medical professional;</li>
<li>Historical evidence of fabricated illness should not alone be the basis upon which a decision is made that an adult&rsquo;s current illness is fabricated;</li>
<li>Medical tests and investigation should be carried out as necessary to confirm the presence (or not) of an illness.</li>
</ul>

Indicators of Fabricated or Induced Illnesses in Adults

<p>The following list is not exhaustive:</p>
<ul>
<li>Reported or actual symptoms are not explained by any medical condition that the adult is, or may be experiencing;</li>
<li>Physical examination/results of medical investigations do not explain reported or actual symptoms;</li>
<li>There is an inexplicably poor response to medication or treatment of the reported symptoms;</li>
<li>New symptoms are swiftly reported on resolution of previous ones;</li>
<li>Over time, repeatedly presenting to different medical professionals in a range of settings (either with the same or varying symptoms)-including GP hopping and seeking multiple opinions to try and validate symptoms;</li>
<li>Known excessive use of medical websites.</li>
</ul>
<p>Concerns may also be raised by other professionals or agencies who may notice discrepancies between reported and observed medical conditions.</p>

General indicators that an illness may be fabricated or induced

<p>Aside from the general indicators in 3.1 above, the following are some additional things that could indicate fabricated or induced illness by proxy:</p>
<ul>
<li>During health appointments/examinations, the other person does not allow the adult to speak for themselves or limits their opportunities to do so;</li>
<li>Symptoms are not observed in the absence of the other person;</li>
<li>Regardless of the adult&rsquo;s views, the other person is insistent on additional tests/examinations, including repeated requests for tests already carried out, as well as failing to accept the results of tests or examinations;</li>
<li>Regardless of the adult&rsquo;s views, the other person is keen for them to be admitted into hospital, for follow up appointments or referrals to specialist services to be made, or for new medication to be prescribed;</li>
<li>The other person repeatedly presents the adult to different medical practitioners in a range of settings (either with the same or varying symptoms). For example, GP, contacting 101, A &amp; E, walk in centres, pharmacy);</li>
<li>The adult&rsquo;s normal daily activities are being restricted beyond that expected with any medical condition they have.</li>
</ul>

Additional indicators that an illness may be fabricated or induced by proxy

<p>&lsquo;Perplexing presentation&rsquo; is the term used to describe the situation when the current state of health of the adult may be caused by a fabricated or induced illness, but it is not yet possible to confirm.</p>
<p>Assumptions should not be made about the outcome of any assessment or investigations carried out at this time. Sometimes, the cause is a rare or misdiagnosed illness or even misinterpretation of behaviour associated with a known condition e.g., Autism. As such, it is important that the right specialism is involved in any assessment and subsequent determination, so that the appropriate course of action or treatment is taken.</p>
<p>If there is perplexing presentation and there are concerns that the adult may be experiencing fabricated or induced illness by proxy, a safeguarding concern should be raised until known otherwise.</p>

Perplexing presentation

Raising a Concern and the Safeguarding Response

<p>If any of the following apply (or may apply), and the adult has (or appears to have) a need for care and support, the safeguarding duty may apply:</p>
<ul>
<li>Another person has intentionally (or unintentionally) induced the illness (fabricated or induced illness by proxy);</li>
<li>Another person has used coercive or controlling behaviour to force the adult to fabricate or induce the illness (psychological or domestic abuse);</li>
<li>Another person is fabricating an illness in themselves for the purpose of coercing or controlling the adult (psychological or domestic abuse);</li>
<li>The illness has been induced because the adult is neglecting their own needs (self-neglect).</li>
</ul>
<p>For further information, see:&nbsp;<a href="/chapter/disclosure-and-raising-a-concern">Disclosure and Raising a Concern</a>.</p>
<p>When received, the concern should be managed in line with the requirements of the Care Act 2014.</p>
<p>For further information, see:&nbsp;<a href="/chapter/responding-to-a-concern">Responding to a Concern</a>.</p>

Raising a concern

<p>Due to the complexities and challenges of this area of practice, a multi-agency approach is essential to manage risk, investigate and intervene in order to achieve a positive and sustainable outcome for the adult. This includes effective joint working and the sharing of relevant information, evidence and concerns in a timely way to ensure the most appropriate and proportionate response takes place at the right time.</p>

Multi-agency working

<h4>Perplexing presentation</h4>
<p>If there is perplexing presentation (it is not yet clear whether the adult is experiencing fabricated or induced illness by proxy), the safeguarding response should be proportionate and restrictive measures that cannot later be reversed, should not be instigated.</p>
<h4>Enquiries</h4>
<p>Where an enquiry takes place, the practitioner leading it should be mindful of the following:</p>
<ul>
<li>Being open and transparent with the person alleged to have caused harm may not be the best way to gather evidence from them or safeguard the adult at risk. This is because challenging them can cause their withdrawal and can also inadvertently lead to an escalation of &lsquo;by proxy&rsquo; behaviour as they attempt to prove that they are doing no harm and that the adult really is ill;</li>
<li>A person who fabricates or induces illness by proxy can demonstrate a seemingly advanced and sophisticated medical knowledge, and it is important that whoever speaks with them is equally well informed, able to identify inaccuracies and challenge appropriately;</li>
<li>Prior to suspicions arising, the person alleged to have caused harm may have developed a plausible and convincing relationship with professionals involved in the case. To avoid conflicts of interest, and to ensure impartiality it can sometimes be beneficial for whoever speaks to them to not already know them.</li>
</ul>
<h4>Supporting the person alleged to be causing harm</h4>
<p><span style="font-weight: normal !msorm;">In the same way as it is important to understand the r</span><span style="font-weight: normal !msorm;">eason why an adult may fabricate or induce an illness in the</span><span style="font-weight: normal !msorm;">mselv</span><span style="font-weight: normal !msorm;">e</span><span style="font-weight: normal !msorm;">s, it is equally as important to understand the motivators when this is by proxy.</span><span style="font-weight: normal !msorm;"> Not doing so can result in a disproportionate response or increase in risk.</span></p>
<p>Where an external factor such as poverty or housing is identified as the cause, the person should be signposted to or supported to access appropriate support and services to address the issues they are experiencing.</p>
<p>If the person is driven by their own desire for attention from medical professionals, their own need for support should be considered. Without support, their behaviour is unlikely to change, and the adult would remain at continued risk of further harm.</p>
<p>In some cases, the person may be a carer who is fabricating or inducing illness by proxy because they are finding caring too difficult, need additional support or are at risk of breakdown. In these cases, a carers assessment or reassessment of the adult&rsquo;s needs may be a more appropriate and proportionate response to the situation.</p>

Specific guidance for cases of fabricated and induced illness by proxy

<div class="section">
<p>If an adult was known as a child or young person to either fabricate or induce illness in themselves, or was at risk &lsquo;by proxy&rsquo;, it is important that Children&rsquo;s Services share relevant information with Adult Services as part of the transition to adult care and support. This will help ensure that ongoing risks are managed, and that the adult continues to get any support they need from mental health or other specialist services.</p>
</div>

When Fabricated or Induced Illness was a Concern in Childhood

<p><a href="https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/cr223.pdf?sfvrsn=658db320_2" target="_blank" rel="noopener">Royal College of Psychiatrists: Assessment and management of adults and children in cases of fabricated or induced illness (FII)</a></p>
<p><a href="https://www.scie.org.uk/safeguarding/adults/reviews/webinar-fabricated-and-induced-illness/" target="_blank" rel="noopener">SCIE Webinar: Fabricated and Induced Illness</a></p>
<p><a href="https://basw.co.uk/policy-and-practice/resources/fabricated-and-induced-illness-practice-guide" target="_blank" rel="noopener">Fabricated or Induced Illness and Perplexing Presentations</a></p>

Further Guidance

LSAB Escalation Template.docx

lsab escalation of professional disputes template stages 1 - 4appendix one: template for recording escalation/resolution which should be used to record an escalation/resolution on the on vulnerable adult’s record at stage 1.name of adultdate of birthaddressescalation raised by (practitioner)practitioner’s agencyescalation raised with (agency and team)date escalation raised circumstances of escalation (include the reason for the escalation, the nature of the disagreement, what is was about, whether it stemmed from a meeting or referral etc.)how was the escalation resolved?date escalation resolvedif the escalation is unresolved, refer to escalation guidancethe form must be completed by the agency raising the escalation. please email a copy of the form to lutonsafeguardingadultsboard@luton.gov.uk appendix two: triggering of escalation: notification to luton safeguarding adults board (stage 2)this form should be used to notify the lsab that the escalation process has been triggered and the escalation is moving to stage 2.name of adultdate of birthaddressescalation raised by (practitioner)practitioner’s agencyescalation raised with (agency and team)date escalation raised circumstances of escalation (include the reason for the escalation, the nature of the disagreement, what is was about, whether it stemmed from a meeting or referral etc.)why was the escalation not resolved at stage 1? date escalation moved to stage 2the form must be completed by the agency raising the escalation. please email a copy of the form to lutonsafeguardingadultsboard@luton.gov.uk appendix three: triggering of escalation: notification to luton safeguarding adults board (stage 3)this form should be used to notify the lsab that the escalation process has been triggered and the escalation is moving to stage 3.name of adultdate of birthaddressescalation raised by (practitioner)practitioner’s agencyescalation raised with (agency and team)date escalation raised circumstances of escalation (include the reason for the escalation, the nature of the disagreement, what is was about, whether it stemmed from a meeting or referral etc.)why was the escalation not resolved at stage 1? date escalation moved to stage 2the form must be completed by the agency raising the escalation. please email a copy of the form to lutonsafeguardingadultsboard@luton.gov.uk appendix four: informing luton safeguarding adult board about escalation to the lsab independent chair (stage 4)this referral is not a substitute for raising a safeguarding concern and should only be used if attempts to resolve the practitioner’s disagreement at stage 3 have failed.  referrer detailsdate of referral:name of referrer: position/role of referrer:agency and team: contact number: email address: your manager: please note: a referral must be made with the support and awareness of your manager/ agency.adult subject of escalationlast name: first name: date of birth & age: current address: post code: telephone: current level of risk:key:high risk of harmredmedium risk of harmamberlow risk of harmgreenplease provide a pen picture of the adult, agency intervention /involvement and a summary of your concerns, risk /barriers.circumstances of escalation (include the reason for the escalation, the nature of the disagreement, what is was about, whether it stemmed from a meeting or referral etc.)what attempts have been made to resolve this escalation at stages 1-3?disclosure: is the adult/carer aware a meeting is taking place and information may be shared as part of the multi-agency safeguarding approach to the resolution of escalations? please confirmyes / nothe lsabs, with their partners are working to understand if what they do makes a difference. they therefore may wish to ask the adult/carer for their views. please can you confirm if they have agreed to do this? please confirmyes / nothe form must be completed by the agency raising the allegation. please email a copy of the form to lutonsafeguardingadultsboard@luton.gov.ukappendix five: informing the luton safeguarding adults board about successful resolution of escalation at stages 1-3this form should be used to notify the lsab that the escalation process has reached a resolution. name of adultdate of birthaddressescalation raised by (practitioner)practitioner’s agencyescalation raised with (agency and team)date escalation raised circumstances of escalation (include the reason for the escalation, the nature of the disagreement, what is was about, whether it stemmed from a meeting or referral etc.)how was the escalation resolved?at was stage of the procedure was it resolved? (stage 2 or 3?)has the escalation been recorded on the adult’s file? has there been learning for you/your agency from the escalation?name and position of person completing form the form must be completed by the agency raising the allegation. please email a copy of the form to lutonsafeguardingadultsboard@luton.gov.uk 

LSAB Escalation of professional disputes Final.pdf

 1  luton safeguarding adults board  escalation process to resolve professional disagreements  contents • 1. introduction • 2. safety of the adult at risk • 3. stages of the procedure • 4. recording and communicating decisions  1. introduction occasionally situations arise when workers in one agency feel that the decision made by a worker from another agency regarding safeguarding an adult at risk is not a safe decision. effective working together depends on an open approach and honest relationships between agencies.  all workers should feel able to challenge decision-making and to see this as their right and responsibility in order to promote the best multi-agency safeguarding practice.  this policy provides workers with the means to raise concerns they have about decisions made by professionals from other agencies. it aims to: • avoid professional disputes that put adults at additional risk or obscure the focus on the adult at risk; • resolve the difficulties between agencies quickly and openly; • this procedure is not a forum for complaints about professional conduct; • if a disagreement arises within one organisation, internal procedures should be followed and the worker may consider using their agency’s whistle-blowing process.  2. safety of the adult at risk the safety of the adult at risk, and the person’s desired outcomes should be the primary considerations in any professional disagreement. disagreements should be resolved as speedily as possible and at the earliest possible stage in the process. steps must be taken, involving the person wherever possible, to ensure their safety and welfare whilst discussions take place. if an adult is at risk of immediate harm or where delay could cause further harm to the adult, it may be appropriate to initiate the process at an earlier stage.  examples this procedure may be appropriate in the following situations: • whether a concern should lead to a safeguarding enquiry at the screening stage; • whether the police should take action in relation to a safeguarding referral; 
 • who is the most appropriate professional to lead on a safeguarding enquiry; • whether an agency has taken sufficient action following a safeguarding enquiry.  timescales for implementing the procedure:   3. stages of the procedure stage 1: professionals involved initial attempts should be taken to resolve the disagreement between the professionals involved. differences in status and/or experience may affect the confidence of some workers to pursue this unsupported. it may be useful for individuals to debrief with their line manager following some disputes in order to promote continuing good working relationships.  if the process needs to progress to a higher stage, it is important that the professionals involved are included in discussions at each stage of the process. they will be able to provide detail around the issues, information about the person’s preferred outcomes and will know the person well enough to ensure well-informed discussions take place.  stage 2: line managers if the disagreement cannot be resolved at stage one, the professionals should consult a line manager within their own agency to clarify their thinking in order to specify what the disagreement is about and what they aim to achieve through the escalation procedure.  the line manager should raise the concerns and attempt to resolve the disagreement with the equivalent supervisor/manager in the other agency. the line manager should also confirm that steps have been taken to ensure the safety of the adult whilst discussions take place.  at stage 2, the line manager involved should notify the safeguarding lead within their organisation of the dispute and of the outcome, regardless of whether the dispute needs to progress to stage 3.  stage 3: organisational safeguarding leads if the disagreement is not resolved at stage 2, the line managers should request that their respective safeguarding leads attempt to resolve the professional disagreement.   it is important that the professionals involved in the original disagreement are included in discussions. they will be able to provide detail around the issues, information about the person’s desired outcomes and will know the person well enough to ensure well-informed discussions take place. high risk of harm red medium risk of harm amber low risk of harm green within 24 hours with 3 working days within 5 working days 
  the safeguarding leads should confirm that steps have been taken to ensure the safety of the adult whilst discussions take place. it may be helpful to convene a multi-agency safeguarding meeting or best interest meeting to review risks to the individual and ensure an interim protection plan is in place. at stage 3, the safeguarding leads in the organisations involved should notify the safeguarding lead within their commissioning organisation of the dispute.  stage 4: safeguarding board representatives if the disagreement is not resolved at stage 3, the matter should be referred to the agencies’ nominated luton safeguarding adults board (lsab) representative. they should agree a resolution with their colleagues at board level.  board representatives must be mindful of the need to resolve disagreements as speedily as possible, ensuring that the safety of the adult at risk is the primary consideration.  4. recording and communicating decisions at all stages of the process actions and decisions must be recorded in the case record and shared with relevant professionals, including professionals involved in the original disagreement. there should be written confirmation between the parties about the agreed outcome and how any outstanding issues will be pursued. it is good practice to copy these to the lsab so they can understand the themes and good practice in resolving professional disputes.  


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