SAR Andrew - published July 2026
The Norfolk Safeguarding Adults Board has today (23 July 2026) published the findings of a Safeguarding Adults Review in respect of Andrew, a 56 year old male who died in autumn 2024.
Background
Andrew lived in cluttered and unsanitary conditions. In the year before his death, he was admitted to hospital five times, all but one lasting at least a week. These were occasioned by attacks of vomiting, dizziness, falls and weakness due to health difficulties relating to Type 2 diabetes and daily alcohol consumption. He lived alone and had limited contact with others, relying on deliveries or neighbours for basic needs.
There were ongoing concerns about self-neglect. Andrew's home was often in poor condition, with unsanitary kitchen and bathroom areas, mouldy food and limited heating. Although several agencies were involved in supporting him, there was limited coordination between services. Safeguarding concerns were raised, but no formal enquiry was undertaken as Andrew declined most forms of support, accepting only minimal help.
Andrew was socially isolated, he declined medical advice to begin insulin treatment and often refused or disengaged from care services. In September 2024, a welfare check was requested but did not meet the threshold for policy entry at the time. A week later, following further concerns, police entered his home and found him deceased.
Key themes explored in this review:
- How might professional curiosity have made a difference?
- What efforts were made to engage and build relationships with Andrew?
- What support services are available to those who have served in the armed forces?
- Why wasn't there a coordinated multi-agency response in relation to the concerns about his environment and self-care? If there was, would he have been found and potentially offered support sooner?
- What pathways are in place in Norfolk for people with a dual diagnosis, and why were these not implemented with Andrew?
- What processes are in place in Norfolk for people who decline diabetic medication, and how are their wishes and feelings considered in decision making?
- How did Right Care, Right Person impact on the timeliness of the police response to Andrew?
This report makes 11 recommendations for practice improvement.