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Ms E – published December 2018

The Norfolk Safeguarding Adults Board (NSAB) has today (12 December 2018) published a Safeguarding Adults Review into the death of a woman living in a Norfolk care home. Our thoughts are with the family who have lost a loved one. This review has been carried out by Norfolk Safeguarding Adults Board, and the independent chair wishes to record her condolences to the family.

Ms E was generally a well lady with full capacity, who used a wheelchair. Ms E occasionally suffered from falls. 

Ms E had been a resident at a Norfolk care home since April 2011, when she entered as a self-funding resident following a hospital admission.

When she went to hospital on the morning of 9 November 2016 she was found to be suffering from severe hypothermia and pneumonia. She passed away that afternoon.

The care home was an old, poorly-insulated building with high ceilings and large rooms. Its heating and hot water ran on two boilers dating back to the 1960s, which were run alternately for short periods in order to produce the full load of the output required for the building. One boiler failed in the early summer of 2016, leaving the home reliant on the second, which itself failed in October 2016. As as a result, the home lacked hot water and heating for a number of weeks. Both boilers had been the subject of condemnation notices issued in 2013. Temporary measures (involving portable heaters, hot water conveyed in jugs, and temporary water heaters) were in place at the time of Ms E’s death, and were being monitored by the Care Quality Commission and the Quality Assurance team of Norfolk County Council’s adult social services department.

Ms E’s admission to hospital resulted in a safeguarding inquiry, jointly led by Norfolk Constabulary and Norfolk adult social services.

Norfolk Constabulary investigated Ms E’s death to determine whether criminal offences had taken place. Concerns about the safety of other residents at the care home triggered an immediate review by ambulance personnel, and ongoing review of their health and social care needs by Norfolk adult social services and the Community Health & Care Trust.

The Care Quality Commission, Quality Assurance and Environmental Health continued to monitor and manage ongoing health and safety concerns in the care home.

In the context of concerns about whether neglect had contributed to Ms E’s death, on 17 November 2016 the Adult Abuse Investigation Unit of Norfolk Constabulary requested that a Safeguarding Adult Review should take place to explore concerns about how the agencies involved had worked together to manage the risks evident in the care home’s situation. 

Before this review started, the owner of the care home took the decision to close it at the end of May 2017.
All residents were re-located. No criminal proceedings were taken by Norfolk Constabulary against any party.

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

SAR E summary

Date: 2018-12-12 / PDF (397 KB)


Date: 2022-02-24 / PDF (985 KB)


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.