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Ms F – 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.

Ms F lived with dementia as did Mr G. The two residents were not related to each other in any way, and their cases are quite different. However, there are overlaps in a number of the learning themes, and NSAB agreed it would be beneficial for both cases to be reported in a joint report.

Ms F lived in a Norfolk care home. She had lived in the care home for a number of years. The focus of this SAR begins in June 2017 after a male resident (Mr Z) moved into the care home as a private placement. Soon after Mr Z arrived at the care home he began to demonstrate challenging behaviour, including resistance to personal care, shouting and verbal aggression. Within a short time, this developed to include violence towards staff members, and then to other residents. Violent behaviour included hitting or punching residents in the face/head. In December 2017 he pushed over Ms F who hit her head as she fell to the floor and fractured the neck of her femur.

Ms F was taken to hospital for surgery, where she remained over the Christmas period. Mr Z was detained under the Mental Health Act 1983. Ms F returned to the care home in January 2018. By this stage, the incident and subsequent surgery seems to have set in motion a chain of deterioration in Ms F’s physical and emotional health.

Although it is not for the SAR to consider causation of Ms F’s death, it appears important to note Ms F’s death occurred some weeks afterwards at the care home on 31 January 2018.

Although the care home described Mr Z's violent behaviour as unpredictable, evidence from the review indicates these incidents could have been better understood and more effectively responded to. The home explained that they did not commonly look after residents demonstrating violent behaviour and the staff team agreed that Mr Z’s needs exceeded their capacity throughout much of the admission. 

NSAB would like to record our thanks to all partner agencies and their staff who work hard to support these reviews.

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

Key learning includes:

  • the need for professional curiosity
  • the way in which challenging behaviour is assessed and managed 
  • the recording of safeguarding data

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)


Date: 2020-01-16 / PDF (810 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.