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Adult P - published February 2024

The Norfolk Safeguarding Adults Board (NSAB) has today (1 February 2024) published a Safeguarding Adults Review into the death,
in August 2021, of a man in his 30s, who lived at home.

The review has been carried out by NSAB, and the board and independent author of this review wish to record their condolences to the family and friends who have lost their loved one.

Adult P lived alone with little information known about his immediate family.  He suffered a back injury in 2019 and, as a result his mobility was limited and he used a mobility scooter.  Adult P suffered with other physical health issues.  He had a history of falls, mental ill health, drug and alcohol use.  Concerns were raised that Adult P was allowing people into his home, and they were threatening him.  A safeguarding adult enquiry was opened regarding financial abuse and exploitation.

Agencies worked hard to support Adult P and reported that his home was in a poor condition, cluttered and hoarded.  Subsequently, after experiencing a fall at home in August 2021, Adult P activated his community alarm to request assistance.  Unfortunately, when an ambulance arrived the next morning, Adult P was found to have passed away.

This review specifically examined the factors contributing to the delay in responding to the alarm and the circumstances surrounding his death.  In doing so, it provides important system learning on the role and use of alarm systems to support individuals who are living in the community.

Key themes explored:

  • the effectiveness of the responses to the initial safeguarding concerns (in September 2020)
  • the response of the community alarm provider
  • the assessment of risk to Adult P by his housing providers, and their responses
  • the multi-agency response to Adult P's mental health concerns about his safety

The NSAB and its partners fully accept the report and its six recommendations.  The partnership is working now on the actions to be taken to address these recommendations.

The review was delayed due to difficulties in securing an independent author.  The first panel meeting was held at the end of October 2022.

Under the provisions of the Care Act 2014, all safeguarding adults boards are required to undertake a Safeguarding Adults Review, overseen by an independent report writer, in order to learn lessons and improve practice when a situation arises with a person in their area who requires care and support, where doubts have been raised about the quality of service that they received.

The key aim of the SAR is not to investigate or apportion blame, but to examine professional practice and adjust this practice in light of lessons learnt.  These lessons are vital to reduce the risk of reoccurrence.


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