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Chapter 4: Social circumstances in the 6 months
prior to death
What is in this chapter? This section
contains information on the social circumstances and living
arrangements of all people for whom data were available
within health, social work and independent sector case
records covering the six months prior to their deaths. The
purpose of this chapter is to try to understand the social
context within which these individuals functioned as part
of their community - their personal characteristics; where
they lived and with whom; how they spent their time;
whether they had experienced particular life difficulties
in the period prior to death. This information could help
identify risk factors which may have impacted on the
circumstances of their death or advise on those areas of
the family or community in which an intervention might
reduce the negative impact of the event.
Where did the information come from? Data
were drawn from two different sources in order to build as
full a picture as possible.
1. Information was extracted from all available case
records (health, social work and independent sector)
relating to the 237 people who had been in contact with
services in the six months prior to a drug-related death in
2003.
2. Information on occupation, relationships, contact
with family and friends was drawn from the 300 files
obtained from the offices of the Procurator Fiscal.
When necessary, data from the different sources have
been described together to add to the richness of the
available information.
Introduction
Obtaining information from personal case records should
help to individualise these deaths, giving us a unique
opportunity to create a more detailed psychological and
social profile of all individuals that have been
categorised as dying in drug-related circumstances in
Scotland in 2003. This process also gives an opportunity to
understand the quality of information that services gather,
as part of normal practice, on those who attend health and
social care services.
The individual, their family and social
supports
Elements of this information, mainly contained within
fiscal files, have been presented in a previous section of
this report. This chapter will describe information
gathered from all available health, social work and
independent sector case files for those 237 people who had
attended services in the six months prior to their
deaths.
The individual
Of those 237 people in contact with services during the
six months prior to death, information on ethnicity was
available for 117. Of these, 114 (97%) were described as
"white". The remainder were from minority ethnic groups. Of
300 fiscal files, 190 cases identified ethnicity. All were
described as "white".
Information on educational attainment is available for
123 people (52%). Of the 123, 49 left school before the age
of 16 years (40%), 59 left at 16 years (48%) and 15 left at
17/18 years (12%). There was no information on
qualifications attained.
Information on training and initial employment is
available for 119 people (50%). After leaving school 13
(11%) went onto further education, 27 (23%) went into
vocational training, 57 (48%) went into employment and 22
(18%) were unemployed.
Activity and employment
Of those 237 people in contact with services during the
six months prior to death, up to date information on
employment status during this period was scant in all
casefiles making detailed interpretation of this data
difficult. Information on income was available for 125 of
the 237 (52%). This showed that, of the 125, 105 (84%) were
unemployed during the six months prior to death. There was
no information on daily activity or routine.
Fiscal files did contain some occupational details in
123 (41%) of the 300 files available. Fifty-seven (46%) of
these people were unemployed and 6 retired. In the case of
the other 177 people (59%) however, no information was
available on occupational status. Twenty-six people
(including 5 whose occupation was not recorded in the case
notes) were working at the time of their death,
representing 14% of those where data on employment status
were available. Of the 162 people not working at the time
of their death, 29 (17%) were claiming unemployment benefit
and 13 (8%) were on sickness or incapacity benefit.
However, in the remaining 74% of unemployed people, no
information was available.
Case study A male retired divorcee living alone in his
own residence on sickness benefits. There is no
history of polysubstance misuse or offending.
He has a lifetime history involving numerous
deliberate attempts to overdose with the last
occurring over 10 years ago. These had resulted
in brief involvement with psychiatric services.
He has never received a formal psychiatric
diagnosis but records show a history of anxiety
and depression. There is also a history of
chronic back pain of unknown aetiology for over
20 years, resulting in retirement through ill
health. His general practitioner prescribed
opioid analgesia (including morphine),
benzodiazepines and anti-depressants. He died
of acute morphine poisoning and appears to have
taken a deliberate overdose of his prescribed
morphine tablets. This is a case of an atypical gentleman who
presented with chronic pain and possible
dependence associated with his chronic opioid
medication and psychological problems. Several
factors can be identified which may have
predisposed this gentleman to take a deliberate
overdose but there are no obvious precipitating
events or circumstances prior to death. |
Interpretation
Employment and meaningful activity is well recognised as
having an impact on ability to progress in terms of moving
on from a life dominated by drug misuse. Despite this there
is very little available up to date information in current
casenotes regarding occupational status or daily activity
in this population. From the limited information available,
however, there is a suggestion that this population
represents a broad range of skills and occupations. It
should also be recognised that a small number were retired
or suffered chronic illness.
Living arrangements
Of 138 for whom information on living arrangements was
available, 74 (54%) lived alone and 64 (46%) lived with
others. Twenty nine of those were recorded as living with a
partner, 32 with parents and three with dependent children.
Data were unavailable for the remaining 98 cases.
Supportive relationships
Information was sought from records on the nature of
relationships between the deceased and their family and
friends. Specifically information was sought on whether
people had felt close to any particular person and whether
there had been any difficulties recorded in the
relationships with family and friends in the six months
prior to death.
Data relating to these questions were largely missing
with 159 people having no mention of the quality of their
relationships in any recent records. Seventy eight (33%)
did contain such information. Of these, 69 (88%) suggested
a close/supportive relationship with their family while
nine records (12%) did not.
Of the 300 fiscal files, information was available on
relationships for 207 (69%) people. They state that, at the
time of death, 98 (33%) were described as being 'in a
relationship' while 109 (36%) were 'unattached'. In some
cases they also record contacts with friends and family.
Regarding their family, data were available for 214 (71%)
people. Of these 214, 167 (78%) had had contact within
three days of death, 37 within the last few weeks and six
within the last year. Regarding friends, data were
available for 203 (68%) people of whom 188 (93%) had
contact within 72hrs, 13 within the last few weeks and one
within six months.
Interpretation
The lack of information in this area implies that
services do not routinely gather or update information on
living arrangements or supportive relationships. Even when
this is collected, the information is relatively
rudimentary and limits the degree of interpretation that is
possible regarding the social support available for an
individual and the impact this may have on individual
vulnerability. Where data were available, the majority of
people who had died of drug related causes, who had been in
contact with services during the six months prior to that
death, showed characteristics not dissimilar to the general
population - they showed a broad range of educational
attainment and many progressed to employment or training
immediately after completing school, though by the time of
death the majority were unemployed; they lived in a range
of environments, with the majority in stable accommodation;
many were in a positive relationship and were not socially
isolated, retaining contact with their friends and family.
It must be stressed however, that, due to the degree of
missing information in casefiles, this interpretation
cannot be generalised.
Case study Young female. Died of acute intoxication
with methadone, benzodiazepines and
amitriptyline. She was registered as unemployed
(but notes state she was a sex-worker) and was
homeless as her long-term relationship had
ended. She had been admitted to hospital
following a deliberate overdose but discharged
herself against medical advice and was found
dead that evening. She had a complex past history including a
poor relationship with her parents resulting in
foster placement from the age of eight years.
She reported sexual abuse while in care. In
1992 it is recorded that she cut herself
following an argument with a boyfriend. The
notes then record a long history of deliberate
self-harm. Her
GP treated her for
depression from 1992. All of her children had
been taken into care. She was involved in a wide range of
drug-related criminal activities from her
teens. She was referred for detoxification
twice but she always returned to drug misuse.
She was prescribed methadone and diazepam
briefly but failed to attend appointments and
her case was closed. She tested positive for
Hepatitis C in 1998. In the six months prior to
death, her casenotes describe chaotic drug use.
Although she had a history of custodial
sentences, she had no periods of custody in the
six months prior to death. |
Relationship with children
Casefiles show that, of those 237 people in contact with
services during the six months prior to death, 119 (50%)
had children while 55 (23%) did not. No information was
available in 63 (27%) casefiles. The 119 who were
identified as parents, had 185 children. Twenty seven
children (15%) were under five years of age, 110 (59%) were
aged 5 to 16 years and 48 (26%) were over 16. Seventeen of
these children (9%) were recorded as living with a parent
who suffered a drug related death. 78 (42%) were living
elsewhere and 2 were in care. No information on where these
children were living was available in 88 (48%) casefiles.
Of 59 females who died, casefiles record that 16 (27%) had
children in their care at the time of their death.
Information was sought from fiscal files only on
children in the care of the deceased. Thirty two people (16
females, 16 males) are recorded as having 54 children in
their care at the time of death with 16 having one child,
11 having two, four having 3 and one person caring for 4
children. There were 227 cases where there were no children
in the subject's care at the time of death. For 41 people
the situation regarding childcare could not be
determined.
The
CSC and fiscal file datasets were
manually compared using unique identifiers, to determine
any similarities or differences between the populations. 12
of the 16 people identified from casefiles as having
responsibility for children were also identified as having
childcare responsibility in the fiscal files. Of the 32
people identified in the fiscal files as having
responsibility for children, the
CSC data showed that 11 had childcare
responsibilities. In five cases, the
CSC files stated that their children
were cared for elsewhere while in 16 cases the situation
was unknown or not recorded in their files.
Interpretation
Drug users often have complex lives and we must be
cautious interpreting these data. For example, a drug
misuser may not have day to day responsibility for child
care but may see and support their child regularly and be a
significant part of their life. It is clear however, that
of 119 parents who died as a result of a drug-related
death, fiscal files suggest that 32 were responsible for
caring for their children during the six months prior to
death. Fifty four children were being cared for by a drug
user who died. Three quarters of all affected children of
which we are aware were of school age.
The comparison of the two datasets implies that the
quality of basic information on childcare arrangements is
generally poor with no updated notes on the situation
available in the six months prior to the death. Casefiles
had a record of child care responsibilities in less than
50% of those identified in fiscal files. This means that
the information informing decision-making around family
support and child-protection in day to day practice may be
inaccurate. In the context of recent reports (eg. "Hidden
Harm") and published advice on improving practice (
e.g. "Getting our Priorities Right") there are
still people in contact with services about whom we know
little regarding their parental responsibilities. If
available, this information would help identify the risks
to the child and allow staff to better identify the needs
of that family. It must also be recognised that, even if a
child is not directly cared for by a parent who dies, they
will inevitably be impacted upon by that death. If they are
not known, appropriate support may not be made available
for them.
Environment
This section contains information regarding where the
person lived - their accommodation and broader
environment.
Environment - living accommodation
Data on accommodation
at the time of death have been presented in a
previous section of this report. Of those 237 people in
contact with services during the six months prior to death,
general information was available in 168 casefiles (70%).
Of the 237, only 117 (49%) were recorded as living in their
own house or flat. Thirty one (13%) were in unstable or
temporary accommodation. A quarter of people had stayed in
their most recent accommodation for less than six months,
half between 6 months and five years and a quarter had
lived for over five years at the same address. Only eight
people were recorded as having been roofless during the six
months prior to death. Information on Prison is contained
in the next chapter.
Life events
Information was sought from service casefiles on history
of traumatic or significant events in the six months prior
to death. Sixty-seven (26%) of the 237 cases identified via
clinical records had one or more significant events
recorded in their notes within the six months prior to
death (Table 4.1). Eleven recorded two significant events
and four cases recorded three events each.
Table 4.1: Number and type of significant
events recorded in case notes of drug related death
cases in the 6 months prior to death (n=67)
Significant Event | Number |
|---|
Separation due to marital difficulties or
broken off a steady relationship | 25 |
|---|
Bereavement | 17 |
|---|
Child custody issues | 12 |
|---|
Physical illness presented for the first
time | 10 |
|---|
Serious injury, illness or assault to close
relative | 9 |
|---|
Serious problem with a close friend,
relative or neighbour | 6 |
|---|
Psychiatric illness presented for the first
time | 5 |
|---|
Interpretation
Significant life events do appear in the records of a
significant minority of people who suffer a drug-related
death. As drug users experience many such events and
present their difficulties to the professionals working
with them regularly, it is likely that other relevant
events are not recorded. Clinically it is well recognised
that substance misusers do experience high levels of trauma
and negative life events but it is impossible to determine
the significance of the events recorded for these cases. It
is however essential that staff take steps to ensure that
they are fully aware of the stresses being experienced by
an already vulnerable group, as this may allow early
intervention and support.
Conclusions
This chapter explores important social variables that
may have a significant impact on the individual's ability
to cope with negative life events. This information should
have been available for all individuals in contact with
services and it is of concern that in many cases it is not.
It is likely that more detailed information was recorded at
the time of initial assessment by a service. The limited
information that was available with regard to the previous
six-month period, however, highlights the need for staff to
regularly review individuals' social circumstances. This is
of particular importance regarding child care
responsibilities. With the limited clinical information
available this study has identified no social risk factor,
knowledge of which will prevent drug-related deaths.
Key Points
- Information in casefiles, as it is currently
collected across Scotland is sparse, inconsistent and
difficult to cross-reference. A standardised,
well-validated method of collecting agreed data on all
drug deaths would ensure that any relevant social risk
factors may be identified.
- The lack of up to date relevant information in many
of the casefiles, which would be required to organise
an integrated care plan is a concern. The availability
of rich, up to date information must form part of good
practice in the management of drug misusers.
- Risk assessment is not routinely recorded. Good
quality standardised information will allow
identification and prioritisation of potential risk
factors in this vulnerable population which could
reduce future morbidity and mortality.
- Staff in all settings should be trained to
comprehensively assess drug misusers and to ensure that
regular updates of essential information (
e.g. regarding childcare responsibilities,
life events
etc.) are recorded to allow improved
awareness of a person's needs and greater evaluation of
the significance of personal and social factors.
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