Key findings

1. People experiencing self-neglect are more at risk if professionals fail to assess mental capacity.

The Mental Capacity Act 2005 requires agencies to assume a person has capacity unless it is established that they lack it. However, misinterpretation of this principle in the cases covered by the SARs led to mental capacity assessments not being carried out. Assessments were not completed even when professionals observed concerning events, such as service-users disengaging with service provision, making significant unwise decisions, and/or having diagnoses which may have impacted upon their decision-making. Worryingly, mental capacity assessments were often not recorded in writing. Assessments which were recorded often lacked detail and clarity about who carried out the assessment and its outcome. This lack of transparency and accountability could expose social workers and their employers, as well as adults in their care, to unnecessary risk.

2. Safeguarding processes failed to protect people with capacity

In the cases covered by SARs, professionals sometimes used capacity to justify not intervening in cases of probable self-neglect, therefore leaving people at considerable risk. Social care practitioners with excessive workload pressures may be at risk of using capacity as a tool for ‘disposing’ of cases, whether consciously or unconsciously. Promoting autonomy and supporting protection should not be mutually exclusive but balanced to best serve people experiencing self-neglect.

3. Assessments lacked nuance and scope

3.1 Complex and traumatic life experiences

SAR authors questioned the extent to which people with traumatic life experiences were able to imagine alternatives to their current living situations. Professionals appeared to have given little consideration to long-term impacts of trauma on cognition, interpersonal relationships, and people feeling overwhelmed in moments of crisis, and the possible implications for mental capacity

3.2 Substance misuse

Consideration of the long-term impacts of substance misuse and addiction on decision-making was limited in the cases covered by the SARs. The Mental Capacity Act 2005 does not acknowledge these impacts, with explicit consideration only of the immediate effects of intoxication.

3.3 Executive capacity

Executive capacity is “the planning, initiation, organization, self-awareness, and execution of tasks”. In the cases covered in the SARs, assessments lacked a thorough consideration of executive capacity. The Mental Capacity Act 2005 states that a person is unable to make a decision if they are unable to “use or weigh” the relevant information, which could be interpreted as inclusion of consideration of executive capacity. However, assessment of executive capacity could be promoted much more clearly and explicitly in the Act. Existing research on the connections between executive capacity and self-neglect is limited.

3.4 The notion of ‘choice’

Application of The Mental Capacity Act 2005 usually assumes that people experiencing self-neglect are making discrete ‘decisions’ to not carry out self-care activities. However, self-neglect may instead develop through a series of ‘non-decisions’. Simplistic notions of capacity and choice may have limited applicability where people are reproducing the only lifestyle they know.

The SARs highlighted that people may be encouraged or discouraged from accepting support because of features of their relationships with professionals. Professionals may empower individuals by informing them of a variety of appropriate options for meeting their self-care needs, or conversely decrease the person’s motivation to engage by failing to offer personalised support.

‘Choice’ is not a culturally or politically neutral notion. Different cultural backgrounds come with different expectations of who makes decisions and how. ‘Independence’ as the favoured goal, with personal choice assumed to further this, serves a political ideology which centres individual responsibility and seeks to minimise state responsibility. In some cases ‘interdependence’, which emphasises how people exist and meet goals in relationship with other people and resources, may be a more appropriate goal for the safety and wellbeing of people and communities.

1.5 Professionals’ lack of confidence in assessing capacity

Throughout the SARs, professionals were noted to lack confidence in assessing capacity. In a number of cases some professionals incorrectly believed assessment of capacity not to be their responsibility.