Alcohol-Related Tragedies: Learning from Reviews

1. Adroddiad Alcohol Change UK– Dysgu o drychinebau – BRIFF 7 MUNUD The Alcohol Change UK report – ‘Learning from tragedies’7 MINUTE BRIEFING

2. 1. Cyflwyniad 1. Introduction • Roedd adroddiad Alcohol Change UK, ‘Learning from tragedies’, a gyhoeddwyd ym mis Gorffennaf 2019, yn dadansoddi 10 adolygiad diogelu oedolion (SAR) ac un adolygiad diogelu annibynnol yn 2017 lle’r oedd alcohol yn berthnasol i farwolaeth yr unigolyn, boed o ganlyniad i broblemau iechyd, lladd neu hunanladdiad. • Ym mhob achos, nid oedd fawr neu ddim ymgysylltiad â’r gwasanaethau, tra bo hunan-esgeulustod yn gysylltiedig â defnydd o alcohol mewn naw achos; mewn chwe achos, hunan-esgeulustod a gwrthod gwasanaethau oedd y prif ffactor oedd wedi arwain at farwolaeth. • The Alcohol Change UK report, ‘Learning from tragedies’, published in July 2019, analysed 10 safeguarding adult reviews (SARs) and one independent safeguarding review published in 2017 where alcohol was relevant to the death of the individual, whether as a result of health problems, killing or suicide. • In all cases, there was little or no engagement in services, while self-neglect was explicitly linked to alcohol use in nine cases; in six cases, self-neglect and refusal of services was the main factor leading to death.

3. 2. Canfyddiadau 2. Findings • Wrth gynnal Adolygiadau Diogelu Oedolion, dylai’r tîm SAR gael mynediad at a gwneud defnydd effeithlon o arbenigedd annibynnol mewn camddefnyddio alcohol er mwyn asesu rôl alcohol yn y digwyddiad, a sicrhau bod gwersi’n cael eu dysgu’n effeithiol. • Dylai awdurdodau lleol sicrhau bod oedolion diamddiffyn gyda phroblemau alcohol yn derbyn cefnogaeth i ymgysylltu â gwasanaethau a dylid cefnogi gwasanaethau i addasu er mwyn iddynt allu darparu gwasanaeth gwell i’r oedolion hyn. • Yn benodol, dylai bod cefnogaeth ar gyfer systemau amlasiantaeth sy’n gallu cydlynu allgymorth pendant a gweld y dasg o gynhyrchu ymgysylltiad cadarnhaol fel gweithred bwysig ar ei phen ei hun. • When carrying out Safeguarding Adult Reviews, the SAR team should always have access to and make effective use of independent expertise in alcohol misuse in order to properly assess the role of alcohol in the incident, and to ensure that lessons are effectively learned. • Local authorities should ensure that vulnerable adults with alcohol problems are actively supported to engage with services and should support services to adapt so that they can better serve these adults. • In particular, there should be support for multi-agency systems that can coordinate assertive outreach and view the task of generating positive engagements as an important action in its own right.

4. 3. Canfyddiadau 3. Findings • Dylai pob gweithiwr proffesiynol sy’n gweithio gydag oedolion sy’n ddibynnol ar alcohol fod wedi derbyn hyfforddiant i gydnabod y rôl gymhleth sydd gan alcohol wrth ddiogelu oedolion, bod ‘dewis rhydd’ yn aml yn gynllun nad yw’n gynorthwyol, ac i osgoi stigmateiddio yfwyr. • Dylid cynhyrchu canllawiau ar gyfer ymarferwyr o ran sut y gellir rhagamcan lefelau yfed pobl yn well, drwy ddefnyddio ffynonellau o dystiolaeth yn ogystal â hunan-adroddiadau, megis tystiolaeth weledol o yfed yr unigolyn. • All professionals working with alcohol-dependent adults should be trained to recognise the complicated role that alcohol plays in adult safeguarding, that ‘free choice’ is often an unhelpful paradigm, and to avoid stigmatising drinkers. • Guidance should be produced for practitioners about how to better estimate someone’s level of drinking, by using sources of evidence additional to self-reporting, such as visual evidence of the person’s drinking

5. 4. Canfyddiadau 4. Findings • Dylid cynnal gwaith comisiynu gwasanaethau alcohol mewn modd sy’n lleihau lefelau trosiant staff ac yn cydnabod pwysigrwydd cysondeb wrth gefnogi pobl gydag anghenion cymhleth. • Mae angen buddsoddiad sylweddol mewn gwasanaethau trin alcohol, gyda nifer o’r buddsoddiadau’n cyfrannu at fodelau gwasanaeth fel ‘allgymorth pendant’ sy’n cefnogi’r unigolion sydd fwyaf agored i niwed a diamddiffyn. • The commissioning of alcohol services should be carried out in a way that minimises levels of staff turnover and recognises the importance of continuity in supporting people with complex needs. • Significantly greater investment is needed in alcohol treatment services, with much of that investment funding service models like ‘assertive outreach’ which support the most at-risk and vulnerable individuals.

6. 5. Canfyddiadau 5. Findings • Dylid datblygu canllawiau cenedlaethol o ran sut i asesu risg yn ymwneud ag alcohol, gan gynnwys sut i fynd i’r afael â’r posibilrwydd o dan-adrodd am ddefnydd o alcohol. • Dylid diwygio Cod Ymarfer Deddf Galluedd Meddyliol 2005 i gynnwys canllawiau penodol ar gyfer gweithio gydag unigolion sy’n camddefnyddio neu’n ddibynnol ar alcohol, yn enwedig pan fo’n debyg fod ganddynt anghenion cymhleth. • National guidance should be developed on how to assess alcohol-related risk, including how to address potential under-reporting of alcohol use. • The Mental Capacity Act 2005 Code of Practice should be amended to include specific guidance for working with individuals with alcohol misuse or dependence, especially when they are likely to have complex needs.

7. 7. Canfyddiadau 7. Findings • Dylid cynhyrchu canllawiau cenedlaethol ar gymhwyso Deddf Galluedd Meddyliol (2005) i bobl gyda galluedd newidiol oherwydd camddefnydd alcohol. • Dylid datblygu canllawiau cenedlaethol i gymhwyso trothwyon diogelu i bobl sy’n hunan-esgeuluso oherwydd camddefnydd alcohol. • National guidance should be produced on applying the Mental Capacity Act (2005) to people with fluctuating capacity due to alcohol misuse. • National guidance should be developed on applying safeguarding thresholds to people who self neglectdue to alcohol misuse.

8. 7. Canfyddiadau 7.Findings Gellir canfod copi o’r adroddiad llawn ar https://alcoholchange.org.uk/publication/learning-from-tragedies-an-analysis-of-alcohol-related-safeguarding-adult-reviews-published-in-2017 A copy of the full report can be found at https://alcoholchange.org.uk/publication/learning-from-tragedies-an-analysis-of-alcohol-related-safeguarding-adult-reviews-published-in-2017