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SAR L, M and N - published August 2022

Norfolk Safeguarding Adults Board (NSAB) publish a Safeguarding Adults Review (SAR) which focuses on incidents that occurred at a private mental health hospital in Norfolk. 

The review considers concerns about Milestones Hospital, regarding the number of safeguarding incidents, in particular self-harming, between 1st July 2019 and the closure of the hospital in February 2021. Most of the incidents involved three patients (for the purposes of the report, we have called them L, M and N).

The concerns centred around patient care and the lack of reporting to multi-agency partners, as self-harming and hospital admissions increased.

Key themes explored:

  • the multi-agency responses to multiple Accident & Emergency attendances by the same patients
  • the systems that were in place to enable commissioners of the service to oversee patient safety and quality monitoring 
  • how effectively the cumulative events were considered by the wider multi-agency partnership / system
  • how effective lines of communication were between the placing authorities and the local commissioner

There are six recommendations set out in the main report, with particular focus on improvements at a systems level to ensure:

  • more robust monitoring of private mental health providers by commissioners, including where patients
    are placed from other counties
  • improved communication around multiple events / patterns of concern, including consideration of cumulative risk

The NSAB and its partners fully accept the report and its recommendations.  The partnership is now working to define what actions will be taken to address the recommendations.

Full SAR report

Summary report

Press release

Norfolk Preparing for Adult Life (PfAL) guidance for 16–17-year-olds in Mental Health Services

As part of this review, the need to better promote the available information and resources on the theme of preparing for adult life,
in particular the topic of being healthy as an adult, was identified.

The Being healthy as an adult guide for parents/carers and young people – co-produced by young people, Norfolk County Council, health commissioners, Family Voice Norfolk, City College Norwich and Sidestrand Hall School – has lots of information. This guide is to promote better understanding of the different sources of help and support in Norfolk around physical and mental health needs.

Please share this widely with your colleagues and networks.

There is also really good information under the preparing for adult life section on the Norfolk SEND Local Offer website and on the Just One Norfolk website.