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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


Whorlton Hall SAR – Durham Safeguarding Adults Partnership (DSAP) summit

In the second week of January 2024, Walter Lloyd-Smith was invited by Durham to represent the Norfolk Safeguarding Adults Board at DSAP’s first summit on the Safeguarding Adults Review into the abuse at Whorlton Hall.

 All seven of the ‘system findings’ from the Whorlton Hall SAR are national issues:

 Lack of standards or expertise requirements for provider-led safeguarding investigations

  1. Absence of a sustained relationship of trust with a professional for each individual in a specialist hospital, that is a prerequisite to effective safeguarding responses in such settings
  2. An illusion of advocacy provision for people with learning disabilities, and/or who are autistic in specialist hospitals
  3. Need for closer working between the Care Quality Commission (CQC) and local authorities to improve outcomes from organisational safeguarding enquiries in specialist hospitals
  4. Gaps in guidance and funding responsibilities for emergency specialist hospital closures after organisational abuse or deregulation
  5. No clear national approach or governance mechanism to pull together Building the Right Support, all other relevant initiatives and learning into coordinated and adequately resourced action to transform care
  6. No evidence-base for what made a Clinical Commissioning Group effective at 'micro' commissioning and quality assurance of services for people with learning disabilities and/or who are autistic to inform Integrated Care Systems

 The aim of the summit was to reflect upon these, seeking commitment from key agencies that results in real change.

 Walter spoke at the event about the similarities between the Norfolk SAR for Joanna, Jon and Ben (Cawston Park) and the Whorlton Hall review. These links give a positive opportunity for both boards to collaborate together, as part of the push for change for people with learning disabilities and/or autism. 

The greater the noise, the greater the echo, the greater the learning, the greater the impact

The DSAP summit also heard:

  • about the lived experience of people who access assessment and Treatment Units, their families and their representatives
  • from the Department of Health and Social Care and NHS England about their work to progress the seven national findings
  • from CQC, seeking assurance on specialist provision

 The particular synergies between the two reviews are in the following areas:

  • commissioning of specialist services
  • rights, protection & advocacy
  • NHS England – strengthening mechanisms
  • service closures

Building on the summit, we are talking with DSAP about next steps and how we might draw in other safeguarding adult boards to take this important work forward.

Lesley Jeavons, the independent chair will be chairing a reference group. Key leads from each of the relevant agencies who are responsible for addressing the seven findings will be participating. This includes the Department of Health and Social Care, NHS England and the Care Quality Commission.

Lesley added, “the Durham Safeguarding Adults Partnership is delighted with the level of participation and response we’ve had to the event.  It was particularly important to us that the voices of service users and carers were heard as well as there being an emphasis on the critical role that advocacy plays when people are in receipt of assessment and treatment services. We hope that the enthusiasm and commitment to change which was evident on the day continues as we progress with the addressing the seven findings of the SAR.”