Background

Adult S was a 72-year-old white male, who lived alone in a two-bedroom council flat. He had no immediate family or wider family network. Adult S spoke of a troubled upbringing, mentioning that he was separated from his mother during his childhood.

He was described by professionals as an ’interesting, quirky character’ who could sometimes be ‘challenging’, when questioned during assessments. Adult S tended to share varying accounts of his personal history with different individuals, which occasionally made it challenging to determine the accuracy of his statements.

Throughout his life, Adult S often expressed feelings of loneliness, especially after losing his two dogs, which had been a source of companionship. He shared a strong bond with his neighbour, who over 15 years, extended friendship, and assistance, even going as far as accompanying Adult S to medical appointments, showing their mutual care and support for one another.

Additionally, Adult S had younger adult friends and acquaintances who used his flat as a place to meet and occasionally stayed over. Adult S was said to welcome their company as he was lonely, whilst others worried and raised concerns that he was being taken advantage of.

In the period between November 2021 and January 2022, a number of referrals were received for Adult S following suicidal ideation or overdoses. He stated loneliness and being unhappy, as well as his housing, as precipitating factors.

As Adult S's mental health deteriorated further, he expressed suicidal thoughts and faced increasing difficulties with his personal care. His GP recommended a residential placement or similar support. In February 2022, he was admitted to the hospital following another suicide attempt.

Tragically, Adult S was discovered deceased in his home by his neighbour in March 2022.

Key themes explored:

This SAR has helped us look at:

• cuckooing and exploitation
• the role of housing when safeguarding concerns are raised
• the use of Multi-Disciplinary Team (MDT) meetings
• the assessment of a person’s mental capacity
• effective multi-agency response to mental health concerns raised about a person’s safety

Work has already begun on several of the recommendations including:

• work by NSAB and the Norfolk Community Safety Partnership to look at the viability of using a Norfolk wide Vulnerable Adult Risk Assessment Conference (VARAC) to better coordinate agency responses
• further promotion of NSAB’s Complex Case management* guidance which support workers and agencies, at an early stage, to convene meetings of staff from a wide range of organisations
• promoting the NSAB Managing Professional Difficulties* guidance across partnership where practitioners feel a case is not progressing
• Adult Social Care have completed an audit to check that Care Act assessments are being completed correctly and have an ongoing systemic audit process in place that reviews the quality of Care Act assessments. Case work checks are also made during staff supervisions

*You can find the guidance on our Practice Guidance page

Full report

Executive Summary

Practitioner Guide

7 minute briefing

Action Plan

Published: Thursday 11 July 2024