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This essay gives an overview of the risk assessment and decision making in adult protection. The main purpose of this essay is to bring a more clear concept of risk; meaning of risk assessment and risk management decision making in adult protection and further it will examine existing based on upon research and evidence finally, it will critically analyse national and local reports which are related to risk assessment. It also contains a section dedicated to the specialized agencies in social assistance and their role in helping vulnerable adults, by creating procedures meant to assure the proper protection and care, offering them security, assistance and guidance to create a normal life. Identify a series of definition of risk and risk management for better understanding the concepts that are aiming to develop. Next, it will connect the existent literature review on this topic to own research. Furthermore, it will present the risks that the adults with disabilities are exposed to, that can cause their injury, or even death, as we will understand from a presented case study.
Discussing about risk management, risk assessment, it can automatically presume that are referring to a situation in which something might go wrong. According to Hope and Sparks (2000) risk assessment may only able to identify probability of harm or danger, consider the impact of risk on individuals key and pretence intervention strategies which may reduce the risk or minimize the harm. However, assessment does not prevent risk.
‘Risk level’ (or simply ‘risk’) should be seen as a continuous probability statement, rather than a dichotomous variable (risk or no risk) since risk levels are often not stable but fluctuate over time and context, estimates of risk should be in the form of ongoing ‘assessments’ rather than one-time ‘predictions. “
The above definition speaks about the fluctuations of risks in time and in different contexts. It recommends that risk should be continuously monitored. Further, in their study, the authors refer to clinical risk assessment, a more related issue to this study.
“A frequent suggestion for improving the validity of clinical risk assessment is to take into account predictor variables reflecting the ‘environmental’ or ‘situational’ context in which violent behaviour is likely to occur, in addition to measuring dispositional, historical, or clinical factors. “
(Monham and Steadman 1994, p. 8)
A more precise definition of the term is offered by Oxford Advanced Learners Dictionary (2010, p.1) “the act of identifying possible risks, calculating how likely they are to happen and estimating what effects they might have”. Risk is closely linked to dangerousness, resulting in harm which seems to be agreed means harm to self or others and extend of harm which constitutes a risk in various situations especially adult with learning disabilities.
Brown (2005) states assessment of risk for adult with learning disabilities which should be evolutionary in nature constantly informed and shaped by changes of circumstances upon service users needs. The practice of risk assessment and management is the process of data collection, recording, interpretation, communication and implementation of risk reduction plan (Brown, 2005). According to Kemshall and Pritchard (2001) every human being becomes vulnerable during their lifetime for many of reasons they all respond differently to events that happen to them because of who they are and the lack of support that they have For the risk of learning disability, clinical model of risk assessment have become the norm. There are two kinds of risk that are relevant to work people with learning disabilities, risk of unnecessary exposure to undesirable events or experience, and risk of negative consequences when possible benefits and desirable experiences are perused (William et al, 2006).
Further present a series of acceptance regarding the risk management concept.
“Risk Management aims to facilitate the exchange of information and expertise across countries and across disciplines. Its purpose is to generate ideas and promote good practice for those involved in the business of managing risk.” (Palgrave-journals, 2011, p.1.).
In this definition, the risk management is perceived as a discipline, moreover, as a business solution meant to ease the communication flow and to propose a model for the risk management practice across countries and business areas. The concern of this study is not so general. Main focus is upon the risk management in the protection of vulnerable adults.
Increasingly responding to the risks of others, preventing risks to vulnerable adults or running risks to themselves is all in day’s work for the busy practitioners and manager in the field of social care (Brearley, 1982). Adult with learning disabilities are subject to risk all time due to their vulnerability they sometimes abused by those who have control over them or by those who realize that they are vulnerable because of their disabilities they often find it very much more difficult to assess risk the way most of social carer and services do.
According to Vaughn & Fuchs (2003) adult with learning disabilities they always find this difficult and also fail to recognize any risk at all as they can’t explain due to lack of communication. Nevertheless, take risks because they feel vulnerable to a point approaching hopelessness (Fischhoff et al., 2000). In either case, these perceptions can prompt adults to make poor decisions that can put them at risk and leave them vulnerable to physical or psychological harm that may have a negative impact on their long-term health and viability. According to Kemshall and Pritchard (2001) there has been much debate about a welfare model or a criminal justice model should be adopted.
Alaszewski (1998) states that, risk is used different ways. It is possible to identify a narrow common sense definition of risk which risk is equated with danger and the negative outcomes of events. Kemshall and Pritchard (2001) indicate that, adult’s vulnerable protection systems are likely to come under close scrutiny.
Protecting ‘Vulnerable Adults,’ Valuing People (2010, P. 93) states:
”People with learning disabilities are entitled to at least the same level of support and intervention from abuse and harm as other citizens. This needs to be provided in a way that respects their own choices and decisions”.
Vaughn & Fuchs (2003) state that, the difficulty for a person with learning disabilities is that carers often do feel often they are expected to make these choices for them. The law of negligence often can appear to inhibit decision making personal freedom and choice sit uncomfortably next to the concepts of duty of care and professional liability.
Above the study and definition, it needs to identify the risk that a vulnerable adult was exposed to. However, it will not be able to make precise mathematical calculations to exactly identifying the risk factor that the vulnerable adult was submitted to. These studies are mostly concerned with the risk assessment that a mental disordered person can cause to others and to himself/herself. An orientation towards the abuse that other people or the society, through its system, can cause to a disordered person is not clearly presented.
The murder of Steven Hoskin has been rendered cold bloodedly by a five peoples in St. Austell, Cornwall on July 6, 2006 (BBC, 2007; Daily Mail, 2007). Hoskin was a 39 years old man with an IQ level equal to a six year old child and living lonely in bedsit when the perpetrators made friendship with him to accomplish their brutal task (Society Guardian, 2007; BBC, 2007). Darren Stewart, the ring leader of the gang, along with his accomplices arrived at his apartment during the night of 5th and 6th July, 2006 (Daily Mail Online, 2007; BBC, 2007). Soon they started torturing and burning his body with cigarettes out of their hate toward his learning disability (Daily Mail Online, 2007). Later on, they coerce him to swallow more than 70 pills of Paracetamol which severely damaged his liver (BBC, 2007). Then they dragged him to the nearby viaduct where he was again stamped on and lashed out by the felons (BBC, 2007; Daily Mail Online, 2007). He was then forced to jump from a 100 feet tall bridge (Daily Mail Online, 2007). Later on, he was found dead in the river (BBC, 2007).
The crooks were later arrested and penalized by the court (BBC, 2007). The question arises here is that why this event occurred in the first place? Why the concerned authorities failed to protect him from the perpetrators even after the fact that some agencies (e.g. adult social care) know about his mental condition (Ahmed, 2007) and let him die helplessly? This is the subject of next discussion.
It was found in the investigation report of multiagency that Hoskin has cancelled his contact with the adult social care unit some days before his death (Society Guardian, 2007; BBC, 2007). This unilateral suspension was not taken seriously by the authorities and did not bother to inquire into the matter seriously (Ahmed, 2007). It was also found that he tried to contact many emergency service agencies nonetheless the matter was considered as a routine and over looked by the officials (Ahmed, 2007).
Cornwall Adult Protection Committee (2007) report, before his death Steven Hoskin gave up his social care protection. “Hoskin was placed in a bed-sit by adult social care in April 2005 and he was allocated two hours of help each week, but he chose to cancel the service in August and by September the council closed his case” (Community Care, 2007, p.1). The institutions involved in investigating Hoskin’s death and the reasons for which the specialized social cares agencies failed to prevent his death, didn’t searched on how and why did the man gave up his rights of social care.
The multiagency report further indicated that every single agency (i.e. Police, the housing association, emergency ambulance and adult social care etc.) did posses some piece of information regarding the conditions of Hoskin owing to the complaints of his neighbours or of himself (Ahmed, 2007). On the other hand no one of them has the complete information that can be used to see the big picture of the situation at hand (Ahmed, 2007). Each one of them was analysing the matter in an isolated environment (Ahmed, 2007). Perhaps, this can be better understood by following the jigsaw approach (Aronson, 1990). In this approach, every member of the group has some minor but important piece of information, nonetheless to make the whole picture complete, every ones contribution is essential (Aronson, 1990). Likewise, in the case of Hoskin, every agency has some minute but important pieces of information about him that can be used to make out what is actually going on with him and help can be launched to stop the danger approaching toward him (Aronson, 1990). For example, police knew that Darren Stewart, the main murder of Haskin, has already criminal record nonetheless this information was hidden to the adult social care which has the information that Stewart is now being seen with Hoskin (Ahmed, 2007). If these two pieces of jigsaw put together, it is very easy to conclude that Darren Stewart may be planning to do something wrong to the vulnerable Hoskin. Hence, it is clear that the lack of integration was the first drawback found in the previous setup.
Second main problem was that there was no mechanism to assemble discrete complaints from the same address several times at the emergency helpline service (Cornwall Adult Protection Committee, 2007). In the multiagency report, it is found that police and ambulance services visited the resident of Steven several times however, these individual complaints were not considered sufficient to alert an authority (Cornwall Adult Protection Committee, 2007). At the call centre, each time when a person in emergency calls, the phone is picked by some random person and the information remain isolated from the other people. There was no such system in place that can assemble the complaints from a unique address which can be used to raise alert (Cornwall Adult Protection Committee, 2007).
Third important problem was the lack of effective communication within an emergency service agency (Ahmed, 2007). For example, Carol Tozel, the director of adult social care, was unaware of the death of Hoskin until June 2007 (Ahmed, 2007). Carol Tozel was taken aback at the extreme lack of intra-communication in her department (Ahmed, 2007). Moreover, she was not provided any risk assessment review regarding the unilateral suspension of adult care services by Hoskin (Ahmed, 2007). This may be due the absence of any alert which her agency failed to raise for Hoskin or the common red-tape problem prevalent in governmental agencies almost all over the world.
Another significant issue was the reduction in the budget of social care services agency for disabled and old aged (Forder and Fernández, 2010). The politicians have played a prominent role in the reduction of budget for this purpose (Forder and Fernández, 2010). It is sorrowful to know that there are millions of pounds available for buying bombs to through at Iraq and Afghanistan however there is little money available to spend on the social care services of helpless and disabled persons.
Steven Hoskin was a vulnerable man who did not receive the professional help that he ought to. The specialized institutions mistreated the case and because he had no protection, the man was brutally murdered. Only after Steven’s murdered his case considered and in addition identified as a vulnerable adult. The agencies responsible for social care did not make the clear connections to determine the man a vulnerable adult while he was still alive.
According to the Adult Protection Act.(1989 p.1) R.S., c. 2, s. 1 an
“adult in need of protection means an adult who, in the premises where he resides, (i) is a victim of physical abuse, sexual abuse, mental cruelty or a combination thereof, is incapable of protecting himself therefore by reason of physical disability or mental infirmity, and refuses, delays or is unable to make provision for his protection therefore, or (ii) is not receiving adequate care and attention, is incapable of caring adequately for himself by reason of physical disability or mental infirmity, and refuses, delays or is unable to make provision for his adequate care and attention.”
After learning the atrocities that Hoskin was exposed to, there is no doubt about the fact that he was a vulnerable adult, in need of protection. According to a report issued by Devon County Council (2007, p.1) an abuse to a person in need is also when he/she is neglected and specialized authorities failed to act upon his/her problem. Hoskin’s problems were long time ignored and through the end of his life he did not benefit of the protection guaranteed by his rights as an adult in need, also because of the bureaucracy of the social care system, which at the time implemented a “ration of the time and resources”. Hence, because the man was not considered a vulnerable adult (his needs criteria were established within “low” to “low moderate”), the authorities just pulled him out of their system (An independent management review, cited in Community Care, 2007).
From the Community Care website we find out that social care representatives are being investigated for failing to prevent the abuse upon Steven Hoskin. According to the online publication Community Care (2007), the agencies in charge with protecting Hoskin missed more than 40 opportunities to help the man and to prevent him being killed.
As keep on investigating this subject, other interesting facts about this case are being revealed. According to Health Service Journal (2008, p.8) the man who took advantage of Hoskin’s mental state, into living with him, was also a mental disordered person. “His own history was chaotic: from being a runaway child, he became a violent and self-harming young man, leading a nomadic existence and making frequent suicidal gestures. He had convictions for arson and assault.”
Here is another case of authority’s incompetency. Because of the repeated calls to hospital, the ambulance service representatives acknowledged the fact that Steven Hoskin was sharing his accommodation with Darren Stewart, who was no stranger to them. They even called police to join them in several actions, to Steven’s apartment, because they knew that Stewart, who shared the bed-sit with Steven, was a very dangerous man (Health Service Journal, 2008). Evan so, because neither the police nor the ambulance service communicated this fact to the social assistance institutions, the case was further neglected.
Further discuss about some procedures that the social care institutions need to follow for avoiding cases like Steven Hoskin’s to happen. Actually, Hoskin’s case was the base of many new regulations for the social care institutions: No Secret refers to this case.
Created in November, 2003 the Adult Protection and Decision Act. “Provide a rate of tools to assist adults (19 and older) who have some diminished ability to make their own decisions” (Health and Social Services, 2010 p.1). The No Secrets (2000) guidance refers to the adult being any person of 18 and older. According to Health and Social Services (2010), the tools refer to decision making and representation agreements, guardianship appointed by court and adult protection for persons who are unable to look out for them and to search for help when abused or neglected.
Hence, the Health and Social Services (2010) definition of a vulnerable adult, the adults who need protection are the ones who are not able to make their own decisions Studying Hoskin’s case; we learnt that the man cancelled his social care assistance. Knowing these facts, an interesting question arises how was Steven Hoskin allowed to cancel his social care program if he was acknowledged as a vulnerable patient, incapable of taking decisions and to protect himself?
Unfortunately there have no evident information to understand the context in which the man gave up his social care rights and what authority and on what grounds approved the man’s request, as these issues were not investigated. The single information that have for this issue, was found in the Community Care article (2007), which presented Ray Jones’ (former social service director Cornwall Council) findings on the case. The Cornwall Council was, at that time, limited to adult care with critical needs. As seen above, Hoskin was considered a low to medium low case, so his was dropped, according to Ray Jones. This is the only statement that we found regarding Hoskin’s cancellation of his social assistance rights.
No Secrets (2000) sates that, guidance defines the term abuse as “a violation of an individual’s human and civil rights by any other person or persons.” (2:9).
Cornwall Adult Protection Committee (2007) presents in its serious case review study the measures created in order not to neglect adults with mental disorders and to prevent them of being harmed. A first recommendation would be to identify the disabled adults who live in a certain community (within conferences and meetings between multi-agencies meant to discover the persons who abused the ambulance or police services and that neighbors identified as problem-makers or disordered persons; by enhancing the communication between the social care institutions through trainings and communication conferences; by improving the information sharing across the statutory agencies; by raising community awareness and understanding about the identity and the possible behavior of vulnerable adults).
The No Secret (2000), guidance also imposes procedures for the statutory agencies to follow, when dealing with a case of vulnerable adult abuse. It is needed to indentify the “responsible and relevant agencies” (3:14). This is a very serious concern, because in order to understand how a vulnerable adult should be taken care of, one needs to understand which the institutions are involved in offering protection and support to vulnerable adults. Among the statutory agencies, such as commissioners of health and social care services, providers of sheltered and supported housing, police, regulator services, the guidance also specifies other actors as relevant agencies: voluntary and private sector agencies (3:14).
The guidance also suggests creating a multi agency management committee, which should consist of the leaders of the appointed agencies, in charge with identifying objectives and setting priorities, coordinating activities between agencies, creating training programs, monitoring and reviewing the progress of the institutions responsible for the vulnerable adults’ welfare. (3:15).
From studied case, Steven Hoskin was also the victim of the agencies’ negligence. The specialized institutions who were in charge with the man’s health status did not communicate amongst each other the reactions that they observed his behaviour.
Other actions established in the No Secret’s (2000) guidance frameworks, to identify roles and to appoint authority; to develop procedures that need to be followed by the agencies involved in the social care system. To protect the vulnerable adults’ confidentiality, as much as possible (the act specifies that a disabled person’s identity should only be communicated on need to know basis); to involve the local authority in this matter (for instance, local police should work closely to the directly appointed agencies by communicating their observations) and all the actions that the multi-agency management committee undertake should be submitted to an annual audit in order to establish if its policies and strategies were correctly applied (No Secret’s 2000,3 : 15, p 17, 18).
The Adult Protection Committee (2007) serious case review, also proposes an induction procedure, as part of the training policy, which is to be undertaken every three years. Within the training plan, as part of the supervision, there is also included a day to day supervision. (Cornwall Adult Protection Committee 2007, p.16). These procedures are followed in Cornwall district but this seems to be an effective model that could be established in the social care system, in general.
Following these rules and suggestions, the risk assessment is supposed to decrease. Just by communicating certain observation that an institution makes upon a vulnerable adult, this could bring many changes. Should a care assistant observe certain reactions at a disabled person and he/she doesn’t assure that the monitored observations are treated with the proper gravity, the treated vulnerable adult can suffer greatly, because his/her symptoms were not detected on time (Adult Protection Committee, 2007).
This is why, all the social care workers should be trained and their tasks and completion of their work to be daily supervised. This requires a more complex system, in which there should be included different levels of co-ordination. Within such a bureaucratic system, another risk factor interferes, the long communication flow which can cause information losses or redundant data (Adult Protection Committee, 2007). This also encounters a beneficial factor the different interpretation forms of certain information. According to Adult Protection Committee (2007), as in the case of a common work of different specialized social care institutions, the agencies can interpret differently a communicated problem related to the vulnerable adults’ monitored problems. Consequently, inter-communication and the information exchange between multi-agencies are so important. If certain information regarding the disabled adult might seem unimportant for a care institution, one other specialized care agency might find it crucial.
Like in the case of Hoskin, the police and the ambulance service didn’t consider very important the fact the that man made so many phone calls to hospitals and neither the fact that he was living with another disabled man seemed to be reflected as a problem for the police or the ambulance. If these facts would have been further communicated to the social care specialized agencies, the man’s live could have been saved.
According to Sellars (2002) risks change constantly and people grow, change, and develop. It is important to review risk assessment regularly, and aim always to increase choice and freedom for the people with learning disability. The presented and analyzed case is a serious, sad and unwanted example for understanding that the social care agencies, and other departments involved in the protection of vulnerable adults did not properly did their jobs. After studying the reports and the publications that treated Steven Hoskin’s case, conclude that the man was the victim of the institutional abuse. His problems were not treated with seriousness, even more; the man was considered a danger to his community because of his lout outburst and violent behaviour.
Hoskin’s case is a clear prove that the institutions didn’t take into consideration the man’s repeated outburst, obvious factors of risk assessment: his repeated calls to hospitals, requiring ambulance services to his home; the police’s visits to his bed-sit (in many occasions required by the ambulance service, aware of the fact that Hoskin was leaving with a dangerous, ex-convicted man, the noisy visits that the neighbours identified with a few months before Steven Hoskin’s death, coming from his apartment). All these examples were neglected by the agencies responsible for Hoskin’s case. Actually no institution took into consideration that the man was vulnerable. He was known to have severe learning problems, having the IQ of a six year child. These are serious facts which prove that the man was a vulnerable adult, not able to make decisions for his own welfare and not able to take care of himself. The authorities involved in Hoskin’s case didn’t properly manage the man’s life. They didn’t even properly investigated the man’s abuse and the reasons that brought him in the situation that caused his death (what determined him to cancel his social assistance program, or did he really cancelled it, who approved this, how did Hoskin come to share his bed-sit with one of his murderers, months before his death).
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