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Adult R - published June 2024

This review looks at the lessons learnt from the death of a woman aged 82, who passed away in hospital in August 2021.

Three months earlier she had been hospitalised following a stroke, and after treatment she had returned home, in line with her wishes, where she received bed-based care. The woman was in a great deal of pain with pressure sores, as her skin had seriously broken down and this eventually led to her death. An inquest concluded that she died of natural causes: sepsis and an infected sacral ulcer in the context of severe coronary artery atherosclerosis.

Agencies have already made many improvements:

• adult social care, in relation to safeguarding processes
• Norfolk Community Health and Care NHS Trust (NCHC) in relation to pressure ulcer care
• the care agency in relation to its telephony system 
• Integrated Care System in relation to patient record sharing.


On 18 September 2021 Manorcourt Homecare, the agency commissioned to provide care and support to Adult R, submitted a Safeguarding Adult Review referral to the Norfolk Safeguarding Adults Board. The safeguarding board sought information from a range of agencies involved with Adult R, and on 29 March 2022 concluded that the criteria for a mandatory SAR were met.

The review was delayed due to a national shortage in the availability of appropriately skilled lead reviewers and capacity in the SAB business team, but in March 2023 NSAB appointed a suitably qualified independent lead reviewer. With a focus on pressure ulcer care, a second reviewer with specialist knowledge in this field was appointed to work alongside the lead reviewer.

Key words: hospital discharge, equipment provision, pressure ulcer care, escalation pathways, complex bed-based care, interagency communication, mental capacity assessment.

Key themes explored:

  • How robust were the systems in place to provide patient safety and quality oversight from the agencies involved, including the provision of pressure care equipment?
  • Was there evidence of a person-centred approach to care planning, focusing on Adult R's wishes and feelings during assessment of her needs, and care?
  • How effectively were the cumulative events considered by the wider safeguarding partnership, and were actions missed to prevent abuse/harm occurring?
  • Care, quality and oversight of the provider: how were concerns escalated and monitored?
  • To explore and better understand at what point and why pressure care becomes a safeguarding concern
  • How changes to the structure of the community nursing services may have impacted on care to Adult R, including how triage decisions of patient needs are made

The review finds that system learning and improvements are needed in the following areas:

• hospital discharge and ongoing coordination of support to patients with complex needs
• escalation pathways
• pressure ulcer care
• GP safeguarding policies and significant event analysis requirements
• mental capacity assessment
• access to shared care records
• manual transcription of medication
• provision of equipment to people receiving bed-based or fully hoisted care at home
• inter-agency communication
• safeguarding triage and the s.42 Care Act mandate

The NSAB and its partners fully accept the report and its 13 recommendations. The partnership is working now on the actions to be taken to address these recommendations.

NSAB wishes to express its sincere condolences to Adult R's family. NSAB thanks all who contributed to the review: Adult R’s family and friends; the staff within agencies who provided chronological information and IMR reports; participants in the learning event, the members and the two reviewers: the lead reviewer Suzy Braye, who was supported by Nadean Marsh.

The reviewer noted that the levels of openness to reflection and learning that were shown by all involved has enabled important priorities for improvement to emerge from the review.

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.


Full SAR report


Practitioner briefing