There are many aspects of the death of Ellen Ash which are shocking and in some ways her death at the hands of her son Jeffrey, is the least of them. He smothered her in desperation at the effect Alzheimer's Disease was having on her and was imprisoned for culpable homicide. He had rejected help, but a new report says he was let down by agencies who should have insisted.
His mother was let down even more, as health and social services failed to respond to obvious concerns about her care.
One of the most glaring failures the report identifies is a sheer lack of urgency.
Dementia and Alzheimer's disease are regarded as terminal illnesses. That means the sufferer is short of time. So it cannot be right that in March 2012, hospital records were only just flagging up that Mrs Ash "could be a vulnerable adult".
By this time she had been diagnosed since at least May 2010, and known to social services since March 2011. She had been in hospital with numerous infections, was frequently confused, wandering and doubly incontinent. Her legs were bruised from banging into furniture and the heating system at home was broken for so long she was admitted to hospital with hypothermia.
Yet services frequently seemed to operate devoide of time pressure. Mrs Ash was referred for specialist dementia support in July 2011. She was still waiting when she died in March 2013. Absurdly, the team told investigators that the referral would have been prioritised if it had been marked 'urgent'.
Seven days before she died, Mrs Ash was discharged home from hospital. The report says. "Given the further deterioration in her cognitive functioning, a care package of one visit per day was clearly inadequate."
The case was complex, in terms of the statutory powers involved and the need to balance Mrs Ash's wishes, and her son's, against her safety.
However we are in the midst of a process of integrating health and social care and if the two professional spheres cannot work together more effectively than they did in this case then the public can have little faith in that project.
Arms length organisations (Aleos) now widely used by councils across Scotland create another potential interface where communication may break down, and did in this case, with Glasgow Aleo Cordia.
Mrs Ash never had any the independent advocacy she was entitled too. Mr Ash never had a comprehensive carers assessment. There is no point having laws which are ignored, policies which are not followed or assessments about someone's vulnerability or need for nursing home care if no action is then taken.
It is certainly easy to spot mistakes with the benefit of hindsight. It is possible that health and social care integration is addressing some of the communication issues.
But Alzheimer's Scotland says Mr Ash is not the only carer to find him or herself lost in a confused landscape struggling to cope alone. The charity is trialling a system of dementia practice coordinators in five locations, to address this.
Health and social care agencies should look at this initiative. But before that there must be a blunt and honest assessment about whether the failings in this case are replicated in the cases of all vulnerable adults - not just those with dementia.
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