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Mr G – published January 2020

SAR - Mr G (published January 2020)

Today (16 January 2020) the Norfolk Safeguarding Adults Board (NSAB) publishes two Safeguarding Adults Reviews (SARs) into the deaths of a woman (Ms F) and a man (Mr G) who lived in a Norfolk care home. The board wishes to record their condolences and their thanks to both families for their assistance throughout the review process.

Mr G was an elderly man with dementia and a range of other health conditions. In June 2017 Mr G was admitted to an acute Norfolk hospital following an incident in a previous care home which led to him falling and sustaining an injury (not a fracture). While in hospital his behaviour became more challenging, leading to his detention under the Mental Health Act 1983. Mr G was admitted to a psychiatric hospital outside of Norfolk as there was not a bed available at the time in Norfolk.

Shortly after arriving at the psychiatric hospital Mr G was admitted to the local acute hospital with a suspected infection and dehydration. After treatment there was a rapid improvement in the behavioural elements of his presentation. Overall, despite it being an out of area placement, Mr G appears to have had a relatively positive experience of care.

In mid-August 2017 Mr G was transferred back to a Norfolk psychiatric hospital and his experience of this hospital also appeared broadly positive. Hospital staff seemed to understand well Mr G’s care needs and demonstrated an ability to develop and implement an appropriate plan for managing his physical health and behaviour.

In the second week of November 2017 Mr G was discharged from the psychiatric hospital to the care home. This arrangement was made under the 'Discharge to Assess’ (DTA) pathway. (The DTA process provides 28 days of funding to assess clients in a less restrictive environment). DTA does not apply to patients detained or admitted to any mental health hospital. Mr G's bed was held open first for 7 days, which then increased to 14. This would have allowed him to return at any point if necessary. The care home, believing that Mr G was discharged under the DTA process, reported that they were not aware Mr G could return to the psychiatric hospital (although several occasions where such information was conveyed to the care home are noted).

The care home had significant difficulties in effectively managing Mr G and providing him with adequate care. Personal care was often refused by Mr G, or delivered under challenging conditions. The Dementia Intensive Support Team (DIST), who remained in contact with Mr G, noted concerns about the care home's ability to safely manage Mr G but this was not flagged as a safeguarding referral.

Despite their concerns, DIST proposed to discharge Mr G to the care of his GP, based on an apparent improvement in his presentation. The relationship between Mr G's family and the care home broke down over the next 3 days regarding Mr G's care. There was significant concern for Mr G’s physical health and a paramedic was called who arranged for Mr G to be admitted back to hospital.

The ambulance crew who admitted Mr G to hospital were so concerned about Mr G’s physical state that they made a safeguarding referral, querying the possibility that Mr G had experienced abuse and neglect. The care home has disputed the concerns documented by the ambulance service, stating that these concerns were simply those relayed by the family.

Mr G sadly died in hospital 3 days later on 22 November 2017.

The report makes 20 recommendations to support improvements across agencies to protect those who are at risk of abuse or harm.

Key learning from Mr G's case includes:

  • the process of assessment and response to mental capacity
  • inter-agency working and communication between professionals and organisations
  • the process by which care needs are assessed in a hospital environment

A summary of the report, including a learning action plan, and the full report are published here:

Date: 2020-10-22 / PDF (1.5 MB)


Under the provisions of the Care Act 2014 all Safeguarding Adults Boards (SABs) are required to undertake a Safeguarding Adults Review (SAR), 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 they received and deserved.

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 re-occurrence.