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Learning - Safeguarding Adult Review Maria

Learning- Safeguarding Adult Review Maria (published October 2020)

Maria - as identified in the Safeguarding Adult Review report was a retired primary school teacher deemed to have full capacity. She had been resident in a nursing home for 2 years prior to her death at the age of 89 years. Her son would visit monthly which had a noticeable positive impact on Maria’s wellbeing. A Safeguarding enquiry was commenced following Maria’s final admission to hospital. At the time of her death Maria had three large grade 4 pressure ulcers over her sacrum, thigh and chin. She also had skin tears on her arms and legs.

The Review highlighted the importance of effective joined up work across NHS and Social Care commissioners and GPs. It identified the positive role of GPs in communicating with and supporting care homes. The Executive Summary can be read here:

  • How does the practice identify when a matter meets the criteria for a safeguarding intervention or is a “care quality” issue?

An excellent aide memoire developed by the Norfolk Safeguarding Adults Board can be found here:

  • How does your surgery meet the needs of local care homes under the GP Contract which requires local surgeries to undertake regular visits to residents at care homes? Does a named GP/clinician provide regular visits? How does the practice support care home staff to identify what needs to be raised to the surgery?

The review identified that Maria was seen regularly by ‘duty’ doctors however only the specific issue for which they were called, was attended to. The report concluded that individual GPs were often unaware or did not respond to other ongoing medical issues in the time they had to visit patients at the care home. Crucially the GP service was unaware of the extent of care quality and safeguarding concerns.

  • Do you know who the lead GP for Safeguarding Adults is at your surgery? How are safeguarding concerns raised and discussed within the practice? Is your lead GP for Safeguarding Adults attending the monthly Safeguarding lead CCG meetings and is this information cascaded to the practice team effectively?

Suffolk Practices only:
Does the practice understand and appropriately use the Safeguarding framework to support decision making? Guidance and the Framework can be accessed here:

The following guidance may also be helpful to support professional curiosity, decision making and referrals:

Norfolk Safeguarding Adults Board website has a section to support with raising a concern (previously described as ‘making a referral’). This includes a checklist of information you need when contacting the local authority, a flow diagram shows what happens when you raise the safeguarding concern, and some frequently asked questions (FAQs) too:

Raising a concern | Norfolk Safeguarding Adults Board


Safeguarding Adults Team - Norfolk and Waveney CCG
Disclaimer: The information provided is correct at the time of publication

Reviewed 21.07.2021 to update links to NSAB website.