A bereaved daughter had to produce her own adult safeguarding review, after Suffolk County Council and joint safeguarding authorities utterly failed her dad living with dementia. To make matters worse, this was after her father Brian Cayford had died – seemingly due to the local authority’s failings.
Her scathing report exposed a litany of the council and social service’s oversights in her dad’s case – not least its failure to intervene on multiple occasions she’d flagged serious safeguarding concerns over potential neglect and financial abuse.
Her experience details a damning institutional catalogue of errors – right to the very top of the local authority’s adult safeguarding services.
Brian: a caring father and talented carpenter
For years, Diana’s dad Brian Cayford was a skilled cabinet maker, with a knack for woodwork. After retirement, and since losing his wife to cancer in 2000, he’d spent much of his free time in his shed crafting intricate items out of wood.
Most memorably for Diana, Brian wove this talent for working with wood into his love for the people around him. She expressed how:
he had a massive great shed in the back garden, and he’d take himself off and make wooden [items]. Anything out of wood, he could make for friends and for family, all sorts of things.
Now, Diana’s house is dotted with warm wooden reminders of her dad everywhere she turns. She spoke tenderly of the way he worked wonders with it:
he’d start with a piece of wood and just create something so beautiful.
And there’s one item she cherishes in particular that perhaps best encapsulated Diana’s enduring close relationship with her father. She described how:
after 40 years of asking, he finally made me a doll’ s house!
Diana has an abundance of memories like these. Her parents had adopted her when they thought they couldn’t have children – which they then discovered wasn’t the case. Diana was later joined by her sister. In one heartwarming recollection, Diana recounted something poignant her dad had once said to her:
it was around December time and he was doing his calendar. He said, “Can you put the birthdays in the calendar?” And I went, “I won’ t know whose all the birthdays are.” And Dad said, “oh well, I only remember one myself.” I said, “oh, is that yours?” He went, “no, it’s yours, because you’re the best thing that ever happened to Mum and me.
However, a harrowing image of her dad has since supplanted these moving memories of him:
one of his neighbours came to see me and said, “Your dad has been taken into hospital and looks really unwell.” So naturally, I rushed straight up there to see if he was okay. And he just looked like he’d been starved, he looked so emaciated and he was crunched up, he looked like rigour mortis had set in, you know? I’d almost thought, “My God, I’m too late” sort of thing. And that’s the image now that I have of my dad.
It was only days later – in October 2021 – that Brian died in hospital at the age of 88. He’d been living with dementia since at least 2018, when his GP had diagnosed him.
But in the years between, leading up to the dire state Diana found him in in hospital, the local council’s adult safeguarding team had ignored multiple red flags over his care.
Denial of dementia from Suffolk County Council
Diana told the Canary that there was a rap sheet of errors “from the word go”. Crucially, she expressed how it boiled down to:
this denial almost of [his] dementia
Specifically, the council has repeatedly cited the Mental Health Act to refute her allegations of neglect, domestic, and financial abuse. Of course, this was problematic in the context of Brian’s dementia, and later in 2021, an Alzheimer’s diagnosis.
As the Alzheimer’s Society notes:
When a person has dementia their mental capacity can change over time. It can also change in both the short term and the long term. For example, there might be days or even times of the day when the person can think more clearly. This means they may have capacity to make a decision at some times but lack capacity at other times.
Despite this, Diana feels the local authority made little effort to take her dad’s fluctuating capacity into account. Most significantly however, Diana pointed out that having capacity under the Mental Health Act shouldn’t have precluded the local authority from carrying out safeguarding investigations. Yet seemingly, it did. She expressed that:
whether it’s done by design, or whether it’s done by ignorance, or whether it’s done for whatever reason, they appear to have tried to cover up safeguarding issues that they failed to deal with, by using the Mental Health Act, which is not what I made my referrals for.
In other words, the local authority appear to have used the fact Brian had capacity to brush off its safeguarding responsibilities.
Warning signs
The circumstances surrounding this are particularly painful for Diana, since it revolves around her sister’s role in their dad’s care.
From 2013, Diana had moved into her dad’s as a live-in carer. She told the Canary how this had a significant impact on her life plans – but she didn’t for one moment regret being there for her dad. However, around the time of his dementia diagnosis in 2018, Diana’s sister became “uncharacteristically involved” in his care. It was not long after this that Brian issued Diana an eviction notice, without warning. Oddly though, when Diana asked him about this, he seemed unaware of it.
At the time, he was recovering from a urinary tract infection (UTI) and was refusing to take his regular angina and arthritis medication. Diana noted how this wasn’t like her dad – he’d effectively managed his own medication for many years.
There were other warning signs too – not least that Brian made sudden changes to his will – making her sister the main beneficiary. One thing that stood out for Diana though, and grieves her to this day, is the fact he also made changes to his burial arrangements. She expressed to the Canary that:
I know for a fact that my dad would never ever have agreed to be buried one side of town, when our mum is buried on the other side. That if given the right, if he knew what was happening, he would never have agreed to that, never in a million years. And that’s what I cling to – he’s all on his own, they’re both all on their own – when they spent so many years together and they should be buried, they should be together, you know.
For these reasons, Diana had raised concerns over possible neglect, domestic, and financial abuse to the Suffolk Constabulary. The force passed this onto Suffolk County Council’s adult safeguarding team. However, it appears it did very little in response.
Suffolk Safeguarding Partnership: all talk, no action
Diana pointed the Canary to the Suffolk Safeguarding Partnership’s website. It consists of the main bodies involved in safeguarding individuals across Suffolk. Specifically, it includes Suffolk County Council, Suffolk Constabulary, as well as the two NHS integrated care boards (ICBs) situated in the local authority area.
There, it boasts that:
Sections 42, 43, and 44 of the Act underpin the work of the Suffolk Safeguarding Partnership, and set out ours and our partners collective responsibilities around;
- protecting individuals and investigating instances of abuse
- the role of the Safeguarding Adults Boards, and
- conducting Safeguarding Adults Reviews
Yet, from Brian’s diagnosis in 2018 onwards, it either didn’t bother to carry these out at all, or otherwise misapplied these regulations.
Firstly, Section 42 of the Care Act 2014 requires local authorities to carry out enquiries if an adult is at risk of abuse or neglect.
Diana feels there were multiple missed opportunities when the local safeguarding team should have made these enquiries. Instead, after his dementia diagnosis and Diana’s sister’s sudden intervention into his care, it simply assessed if he had mental capacity. Diana hasn’t been able to establish if they treated this as a Section 42 review.
However, she believes this was the first time where the local authority applied the Mental Health Act to decide he didn’t need safeguarding.
There were other glaring instances like this too. In 2021, much of this came to a head. Diana said on this how:
in February/March time 2021 there were a lot of red flags in a very short space of time.
For instance, this included:
- A trip to A&E for a minor head injury following a fall.
- A second trip to A&E for a fall just ten days later, in which he lost consciousness.
Moreover, Diana has proof the council were aware of his deteriorating dementia and vulnerability. Its Adult Care Services had contacted her sister acknowledging this a day after his second A&E visit. Her sister had informed them he wasn’t maintaining his personal hygiene or changing his incontinence pads. Despite all this, when Brian refused carers from the team, Diana later uncovered that:
nobody checked to see if he was in his right mind to refuse that, whether he’d been coerced into refusing that. So they just walked away and left him. So having decided that he was vulnerable, they didn’t follow up – knowing that he had dementia and was forgetful, they just assumed.
Unlawful review of Brian’s care
Eventually, the local authority’s multi-agency safeguarding hub (MASH) team agreed he fit the criteria for a Section 42 review. However, it did so on 25 October 2021 – nine days after Brian had died in hospital.
Despite the fact that Diana had notified head of adult care services Georgia Chimbani that her dad had passed, Chimbani didn’t appear to pass this information on to the MASH team.
It meant that on 26 October, the MASH team sent Diana its report. This detailed how it had determined that Brian needed the review. And in November, by then aware of his passing, it decided to carry it out.
By February, it concluded its Section 42 investigation – closing the enquiry as “inconclusive”.
However, there’s one major problem with this: its findings are unlawful. This is because local authorities cannot legally carry these out once the person has died. Or, in other words, the council cannot actually claim it conducted this, since Brian was no longer alive when it did.
Diana told the Canary how:
the only message I got back was “well, he’s got mental capacity” and he’d already been diagnosed with dementia and I’ve looked at the Mental Capacity Act, and they’ve interpreted the Mental Health Act to try and cover themselves.
In correspondence, ACS told Diana that:
any assessment would have been conducted in line with the guidance given in 2014 Care Act and could only have been carried out with the actual person’s consent if they had Mental Capacity’.
But, as it so happened, the safeguarding team could hardly have known Brian had capacity anyway. Obviously, for one, it couldn’t have checked this during the review, since Brian was already dead. Diana explained how:
on the report it said, “we’ve been trying to get hold of Mr. Cayford. We can’t get hold of him; we keep trying.
On top of this, the report acknowledged it hadn’t spoken to him in over two years. This sent alarm bells ringing for Diana:
Well who spoke to him in the early 2021 and offered him care then? It was all very confusing, and the more I delved in, the more they backed off, and the more they just tried to blank me, and close ranks around it. Which raised my concerns even more, because if they had nothing to hide, then they would be open and honest with me.
Diana forced to do her own safeguarding review
Given all this, Diana felt the local authority had significant questions to answer. However, to get these, she had to do her own investigations.
Specifically, Diana did what the local authority refused to – a review of Brian’s case and how the local safeguarding authorities oversaw it.
This is what’s known as a Section 44 review – also under the Care Act 2014. It stipulates that a local safeguarding adults board (SAB) must carry out a review if:
- There is “reasonable cause for concern” about how local safeguarding teams worked together to safeguard the adult
- The adult has died, and “knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).”
Of course, Diana could reel off a list of reasons the board should have had cause to suspect this. However, the SAB refused to conduct one after Diana requested it in 2022. According to the SAB, Brian’s case:
did not meet the criteria
What’s more, it stated that the SAB was:
satisfied by the County Council’s assessment both of what happened and by your father’s capacity to take his own decisions
Yet, as far as Diana could tell, this seemed to revolve around the unlawful section 42 review and early MHA assessments. Of course, a section 44 review would also have dredged up all these glaring mistakes Diana uncovered. It’s perhaps little wonder then, that the local authority has refused to do this.
Suffolk County Council culture of evasion
If its repeated failures and errors weren’t bad enough, the council’s response since has only made it all the more alarming.
Diana told the Canary council staff have ignored, downplayed, and even sent her emails she has described as “intimidating”.
Initially, Diana said that Suffolk County Council director of ACS Georgia Chimbani had been “very sympathetic” when she first made her safeguarding referral.
Diana highlighted to the Canary that Chimbani has a gilded list of accolades to her name. Notably, her NHS biography states how:
From 2018 to 2022 Georgia was the Association of Directors of Adult Social Services [ADASS] lead for dementia and through this role was worked with the DHSC and other stakeholders to set the national strategic direction for dementia through the Dementia Programme Board. She has been instrumental in setting up and co-chairs the Dementia Action Partnership in Suffolk, a partnership of statutory and third sector organisations working to make Suffolk a dementia friendly county.
What’s more, she sits on the board of the Social Care Institute of Excellence (SCIE), which describes its remit to:
contribute to the development and implementation of better care, support and safeguarding at national and local level.
However, Diana detailed how:
when I told her he was dead, she cut me straight off communications
According to Diana, the council then threatened legal action against her if she continued contacting Chimbani directly via email.
Failing people living with dementia in Suffolk
There were moments when Diana opened up to the Canary about her ordeal where she was visibly choked up. Over three years on from her dad’s death, she has many of the answers, but her peace of mind is no better for them.
Her painstaking work to piece together the whole picture of the circumstances that lead up to her dad’s death have unearthed so many failures from local authorities. No grieving daughter should have to do what she has done to get to the truth. And that’s a big part of the reason Diana has done it too.
Diana has a vast wealth of experience behind her in safeguarding herself. She was a former Suffolk Police safeguarding investigator, with specialist training in child safeguarding.
Others, she realises, wouldn’t be in the same position to do this. She voiced her concern that the safeguarding authorities in Suffolk could be failing other vulnerable adults with dementia and their families:
it worries me that other people without the support network – people suffering dementia on their own or with families that are a long distance away that can’t keep an eye on them – may be relying on this council.
The Canary asked Suffolk County Council for comment – but it had not responded at the time of publication.
A damning indictment of Suffolk County Council
Of course, it underscores a vital question – how many other people living with dementia in Suffolk are the council and its safeguarding partners catastrophically failing too?
For Diana’s dad Brian, it’s now too late. She told the Canary that:
I’m big enough and tough enough to understand that he’s not coming back, but I do feel that they owe him an apology through me, because there were so many warning signs
Her dad’s story is a damning indictment of local authorities’ failure to safeguard vulnerable people living with dementia in Suffolk. Diana hopes they will finally admit to their mistakes so no one else has to go through what she has too.
Featured image via the Canary
