When death comes too soon

Andrew Misell | July 2019 | 6 minutes

Our new report, Learning from tragedies, looks at reviews of the deaths of vulnerable adults in which alcohol was a factor, in order to prevent future tragedies; in this blog Andrew considers one woman’s story.

Death. It’s no one’s favourite topic. But sometimes we have to talk about it. Particularly about the kind of deaths that can be prevented.

Some of us will remember the sentencing in 2016 of two teenage girls for a horrific murder they had committed two years earlier, when they were just 13 and 14 years old. It was the sort of case that attracts a lot of tabloid attention – a cruel and unprovoked attack over period of several hours. As so often, there was a lot of media focus on the killers – on how two people so young became such ‘animals’, such ‘monsters’, so ‘senseless’.

There was less talk about the 39-year-old victim (given the name ‘Carol’ in official documents, although she had another identity all of her own). It was almost as if she had just stumbled by chance into the crime scene. But Carol was no mystery woman. She was well-known in her local area. During the previous three years, Carol had 1,000 direct contacts with healthcare services and was involved in some way in 472 incidents that were reported to the police, often because of her heavy drinking.

Carol was no mystery woman. During the previous three years, Carol had 1,000 direct contacts with healthcare services and was involved in some way in 472 incidents that were reported to the police, often because of her heavy drinking.

Sadly, Carol’s story is not some random outlier. It’s part of a pattern of lives marked by isolation, exploitation, self-neglect, and alcohol misuse. The report Learning from tragedies, published this week by Alcohol Change UK, sets out the stories of Carol and 10 other vulnerable people with complex needs, whose deaths were recorded and analysed in official Safeguarding Adult Reviews, with alcohol flagged as a significant factor in their lives and deaths.

In all 11 cases, opportunities were missed that could have been, quite literally, life-saving. Information was not shared between agencies and people fell through the gaps in a fragmented system. The role that alcohol played in their lives was not properly understood and addressed. Constant changes in services meant that relationships between clients and practitioners were not maintained. Laws that exist to protect vulnerable adults were not always well-understood or well-applied.

Opportunities were missed that could have been, quite literally, life-saving.

As its title indicates, this is a report about learning lessons – lessons such as the need to commission services in ways that minimise staff turnover; the need for active support and assertive outreach for adults with serious alcohol problems; and the need to understand how alcohol functions in many vulnerable people’s lives. Learning from tragedies reiterates the basic message of the Blue Light project: that even people who are resistant to receiving alcohol treatment must not be written off.

No one is pretending that people like Carol are easy to work with. They may well be rude, aggressive and ungrateful. They may show little or no understanding of their own drinking, and little obvious desire to change. Social workers, GPs, paramedics, police and others who encounter them cannot not be expected to be all-knowing experts on alcohol problems. But, with the right training and support, they can become more expert and more able to intervene.

If used carefully and proportionately, laws allowing interventions when someone lacks the mental capacity to consent or refuse could be applied to some people whose ability to decide has been undermined by long-term heavy drinking.

All in all, we could do more for people like Carol. They are not beyond help or beyond hope, and as a society we have a duty to offer them both those things.