The Norfolk Safeguarding Adults Board (NSAB) has today (27 February 2025) published a Safeguarding Adults Review into the death of a man who lived with multiple difficulties.  This is a very sad death and our thoughts are with the family who have lost a loved one. We would like to offer our condolences to Eric's family.

In publishing this review NSAB will be using its findings to strengthen the way agencies work together to protect vulnerable adults in Norfolk.

Background

Eric was a white, British male.  He was in his early sixties when he died by suicide.  He had a long history of problematic alcohol abuse, self-harm, self-neglecting behaviours and suicide attempts.  Eric's poor self-care and self-harming behaviours started when he separated from the mother of his children.  Eric had then been in a relationship with a woman who also had alcohol and mental health issues and, when this relationship ended, Eric's behaviours escalated.  At the time of his death, Eric was living in a care home.

Eric had lived independently however, he was a frequent attender at hospital due to self-harming, falls and poor physical health linked to alcohol use.  During his final admission to hospital in January 2021, he contracted Covid, which rendered him weak with poor mobility.  His adult daughter raised a concern that he would be unable to care for himself at home.  Eric was also deemed to lack capacity to decide where he should live and a best interests decision was made which meant he was accommodated in a series of care homes and inpatient beds.  Eric constantly requested to return home; he had fluctuating capacity and it was considered that he would be unable to care for himself if he returned to independent living.

A diagnosis of Korsakoff dementia was recorded on Eric's records, however there is no evidence that this was officially diagnosed.  The care homes identified for Eric were specifically for dementia patients but Eric did not fit into the environment and they were not equipped to deal with his specific behaviours.

Eric attempted suicide in October 2021, and in November 2021 care home staff found him deceased, having taken his own life.

Key themes explored

• the management of Eric's move from the mental health hospital to the care home, including pre-assessment and decision making on the suitability of the service to meet his care needs
• were the responses to the safeguarding concern while Eric was at the residential care unit effective?
• the voice of Eric, and his desire to return home.  Was this properly explored?
• the understanding, assessment and management of risks associates with self-neglecting behaviour, both in the community and in residential services
• was there an effective multi-agency response to Eric's mental health concerns, particularly around his safety following threats to harm himself and his suicide attempt in October 2021
• how were professionals responding to Eric when aware of the links between his condition and alcohol use, self-harm and suicide attempts?
• how confident are staff from different agencies in recognising Korsakoff dementia; how it presents and the associated risks?
• the suitability of service provision in Norfolk to meet the needs of adults with Korsakoff dementia and the complexities and risks they present
• the assessment of Eric's mental capacity/best interest decision for a move to a more suitable placement when found
• Eric's non engagement with the community mental health team.  How effective were agency and multi agencies responses to Eric and his potential lack of understanding of his condition?
• analysis of Eric's mental capacity at each key decision making point

The report makes six recommendations for practice improvement. 

Full report

Executive summary

Practitioner guide

7 minute briefing

Quick guide: Interface between the Mental Health Act and Mental Capacity Act

You can also watch this short learning briefing from the SAR author Dr Liza Thompson.