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Joanna, Jon and Ben - published September 2021

Norfolk Safeguarding Adults Board (NSAB) publishes an important Safeguarding Adults Review (SAR) into the deaths of three young adults: Joanna, “Jon” and Ben (all in their 30s). They had learning disabilities and had been patients at Cawston Park Hospital. They died within a 27-month period (April 2018 to July 2020).

Joanna, Jon and Ben were admitted to the hospital under sections of the Mental Health Act (1983). Joanna and Jon originated from London boroughs. Ben was from Norfolk. Their behaviour was known to challenge services and sometimes their families. Joanna and Jon had experienced several out-of-family-home placements. Ben had lived with his mother for most of his life. Their placement at the hospital resulted from personal and family crises.

The review makes 13 recommendations for critical system / strategic change. In addition it contains the following key learning for practitioners:

  • the critical role for professional curiosity and challenge
  • the trauma of transition
  • meaningful support for individuals with behaviours that challenge others
  • critical responsibility for staff to advocate reporting and openness
  • where the victim of abuse doesn’t want to ‘complain’
  • the importance of meaningful occupations
  • making sure attention is given to physical health needs
  • mental capacity


Full SAR report (including an annex covering information from Ben's inquest)

Executive summary

Practitioner briefing

Carers briefing

Easy Read

Action plan