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SARs published by other Safeguarding Adults Boards

A number of Safeguarding Adults Boards (SAB) publish links to Safeguarding Adult Review reports and Inquiry Reports. These are very useful sources of information.

Safeguarding Adults Board for Cornwall and The Isles of Scilly and the Safer Cornwall Partnership Board

'Margaret' | published 26 January 2021

This is a joint Domestic Homicide Review (DHR) / Safeguarding Adults Review (SAR) into the death of 'Margaret'. The reviews have been carried out as a single process, and Margaret’s family have been involved from the start of the review.

This case has highlighted how older people can become very isolated if their health or social circumstances begin to deteriorate. If an older person is unable to ask for support, there is an increasing risk to their health and wellbeing. Services that support older people living at home need to be particularly vigilant to the early signs of isolation, domestic abuse, deteriorating physical health or mental health such as dementia and/or welfare concerns. It is important that they are then able to act upon these concerns at an early stage.

Domestic abuse in older people is recognised as requiring particular attention due to the hidden nature of abuse within this age group and the difficulties in identifying and responding, particularly when additional vulnerabilities such as dementia are also present. The combined DHR and SAR found a need for increased awareness of domestic abuse among older people.

Cumbria Safeguarding Adults Board 

'Barry' | published 11 December 2020

Barry died on 23rd May 2019 by taking an overdose of medication in his car parked in his GP surgery car park. Barry left a suicide note with boxes containing prescribed medication and empty blister packs found next to him. Barry was a lonely man with few friends and very limited family contact. Barry lived alone and was not a member of many community groups. He is known to have moved about frequently and moved to Cumbria in the late spring of 2018. Barry suffered from depression and loneliness and accessed numerous services for support during his time in Cumbria. Barry stated to professionals that the death of his mother in 2008 had a negative impact on his mental health.

The review highlighted several key themes as areas for learning and action including:

  • Effectiveness of services assessing and responding to Barry’s needs
  • Co-ordination of services 
  • Referral systems and processes
  • Loneliness

Further reading

East Sussex Safeguarding Adults Board

Adult C | published 2 December 2020

This review explored the circumstances leading up to the death of a 41 year old woman, referred to in the report as Adult C. Adult C experienced significant levels of domestic violence and coercive control, which were particularly severe during the last 12 months of her life, the period which this review focused on. Adult C had multiple complex needs as a result of drug and alcohol dependencyfluctuating mental health (including patterns of self-harm and periods of poor mental health) and homelessness. Her substance misuse led to involvement from Children’s Services and alternative care arrangements for her two children being sought. Adult C was involved in criminal behaviour at times to fund her substance misuse.

Read the full report, Board response and learning briefing here.

Oxfordshire Safeguarding Adults Board 

Homeless Deaths | published November 2020

Oxfordshire SAB has published its review into nine deaths that occurred between December 2018 and July 2019 amongst people who are identified as homeless. The purpose of the review is to promote learning and improve the practice of organisations. The report was written by two independent authors, Dr Adi Cooper and Professor Michael Preston-Shoot involved a number of different organisations and some members of the safeguarding board.

Worcestershire Safeguarding Adults Board

Thematic Safeguarding Adults Review Regarding people who sleep rough | published September 2020

In September 2019, Worcestershire Safeguarding Adults Board (WSAB) identified the experience of five people as collectively meeting the criteria required for a SAR. The experience of these people was united by the fact that they all lived in such a way that they were included amongst individuals sometimes referred to as “rough sleepers.”

Lewisham SAB 

Tyrone Goodyear | published 12 June 2020

Tyrone was a 24 year old man who committed suicide in February 2019. The review examines the circumstances and issues leading up to Tyrone’s death, including homelessness (amid the ‘housing crisis’), mental ill-health and suicide prevention, all linked to Autism Spectrum Condition and learning difficulties.

Cumbria SAB

'Robyn' | published 9 June 2020

Robyn (an 85 year old woman) died in December 2018. She sustained a traumatic head injury in a fall at home in December 2015 which she was not expected to survive. At the time she was discharged from hospital Robyn was in a minimally conscious state. She unexpectedly survived for a further three years. She died in a local hospice after the withdrawal of clinically assisted nutrition and hydration by order of the Court of Protection. Cumbria Safeguarding Adults Board decide to undertake a safeguarding adults review as there were concerns that partner agencies could have worked together more effectively to protect Robyn.

The SAR identified the following themes:

  • adult safeguarding
  • discharge planning
  • Advance Decisions
  • Mental Capacity Act - Best Interests
  • working with family carer's
  • resolving professional disagreement
  • coercive control
  • NHS Continuing Health Care

Learning Brief and full report

North Lincolnshire Safeguarding Adults Board (NLSAB)

Adult A | published 27 May 2020

Adult A was an 87-year-old gentleman who suffered from Alzheimer’s disease. Adult A also had prostate disease and type 2 diabetes. Adult A had been cared for at home by his family until June 2018 when he was admitted to a care home by his family due to a deterioration in his Alzheimer’s presentation. His placement was self-funded. Adult A was taken to hospital twice in July following falls. On the second occasion, medical staff were concerned by multiple bruises and raised a safeguarding concern. The ensuing section 42 enquiry concluded that there were risks identified and action had been taken in relation to the care home. On the second admission Adult A was diagnosed with multiple secondaries from a cancer of an unknown primary source and died as a result of this seven weeks later.

NLSAB commissioned an independently led review following concerns raised by the family regarding how the safeguarding enquiry was undertaken and how partner organisations worked together during that enquiry. The review looked at the involvement of all organisations involved.

A number of learning points were identified in relation to the following themes:

  • Transition from home to a care setting
  • Managing falls and other behaviours in people with dementia
  • The effectiveness of the multi-agency safeguarding system
  • Review of policies and procedures.

Full report, a statement from Adult A’s family and a statement from Moira Wilson, Independent Chair, NLSAB.

East Sussex Safeguarding Adults Board (SAB)

Adult B | published February 2020

In February 2020 the East Sussex SAB published the findings of a Safeguarding Adult Review (SAR) after the death of a 94-year-old woman in September 2017, referred to as Adult B. The woman died in hospital of natural causes but, when admitted, was found to have 26 unexplained injuries including a fractured nose and jaw, as well as old and new bruising to her face, arms and legs. She was diagnosed with sepsis and pneumonia shortly after her arrival in hospital and she died eight days later.

The woman had been living firstly with her grand-daughter and then with her son and his family. They were providing most of her day-to-day care but with support from private care workers and community nurses. Following her death, the SAB launched a SAR to examine the support those professionals had provided and to establish if any lessons could be learnt.

The review focused on events from November 2012 to Adult B’s death in September 2017. The SAR was led by independent reviewer, Fiona Johnson.

Recommendations include:

  • ensuring service users are seen privately and personally away from their families
  • better training for professionals working with complex cases, especially where there may be coercion and control.

The review also questioned whether the arrangements for investigating adults’ deaths at the time, where abuse or neglect is suspected, were sufficient and asked for options to be scoped that reflected the procedures when a child dies.

North Tyneside and Northumberland SAB

Leanne Patterson | published November 2019

Northumberland have recently published a SAR Executive Summary, on behalf of North Tyneside and Northumberland SAB. The review highlighted themes in relation to homelessness and provision, mental capacity and the impact of complex vulnerabilities, and the need for all agencies to make referrals to appropriate Multi-agency processes. The SAR Executive Summary has been published under the name of the adult, Leanne Patterson, at the request of her family.

Lancashire Safeguarding Adults Board

Adult G | published 8 October 2019

Adult G was a 51 year old man who lived alone in rented accommodation, was unemployed and in receipt of benefits. Adult G was known to services including mental health; Adult G had attempted to take his own life in January 2017 and as a result had been admitted as an inpatient on an informal basis. He had memory problems which appeared to result in him accruing overwhelming debt to the point where he could barely afford to eat and he often did not attend appointments leading to him being discharged from services, or not receiving medical treatment. Sadly, Adult G took his own life in June 2017, he was found by his son.

Lancashire Safeguarding Adults Board

Adult I - 'May' | published 11 September 2019

May was a 71 year female who died suddenly at home, post mortem results indicated the cause of death to be sepsis, with evidence of pressure ulcers and acute on chronic cholecystitis. May lived alone, she was extremely overweight with a BMI of 51.8, with multiple health problems and limited mobility; this resulted in
her receiving support 5 times a day from 2 Homecare Provider agencies. She also had input from District Nursing services, GP and had spent time as a hospital inpatient. May exhibited some hoarding behaviours and had a degree of learning difficulties, although agencies did not doubt her capacity to make decisions.
May had periods of low mood and anxiety and was at high risk of Pressure Ulcers due to her very limited mobility. Regular district nursing visits occurred to address May's health needs and reablement support was provided to try to improve her mobility, though she was not always concordant with interventions. Despite
May's complex health needs, her death was not expected. The review highlighted key themes and areas of Learning are:

  • Service user voice and family involvement
  • Case Management
  • Person centred assessment of need
  • Capacity to consent to interventions
  • The home care system 

Full SAR report

Bristol Safeguarding Adults Board

Kamil Ahmad and Mr X | published June 2019

Kamil was a Kurdish asylum seeker who was murdered in 2016 by Mr X, a white British male, whilst both were residents in the same supported living accommodation for individuals with mental health needs. Mr X was convicted of murder in 2017 and is now serving a life sentence.

City and Hackney Safeguarding Adults Board (CHSAB)

JoJo | published June 2019

Safeguarding Adults Review tells the story of what happened to Jo-Jo during the last year of her life. Jo-Jo was 38 when she died.  She was born with Downs Syndrome and she had 2 younger sisters. Her mother cared for Jo-Jo through out her life helping her through school into adulthood. Jo-Jo needed help with many daily living tasks including personal care, eating the right things, managing money and personal relationships. Throughout all of this her mother was the main carer.  
Since childhood Jo-Jo had suffered from eczema which often caused her distress and discomfort. It would sometimes get better but then it would come back again.  Her mother was the main person who applied the creams or dealt with any other medicines. In 2013 Jo-Jo was diagnosed with something called crusted scabies. There were many times when Jo-Jo did not want to go out because her skin condition was so bad and people looked at her, many times she could not go out because the scabs and infection on her feet made it too painful to walk.

Jo-Jo’s skin condition became very bad with most of her body infected and she became quite poorly. On 9th March 2017 mother called the GP to see Jo-Jo at home who was by this time lying on the floor and not able to stand. Her skin condition was very bad. The GP had 2 choices at that time: one was to get Jo-Jo to hospital immediately through A&E which would have involved a lot of hanging about and JoJo might then have been sent home. The second option was to get Jo-Jo seen urgently by a skin specialist the next morning. The GP quite understandably chose the second option and also said this was not eczema but that it was Norwegian Scabies. So the GP spoke to the consultant doctor and made an emergency appointment for the next morning.
The ambulance came the next morning and took Jo-Jo to the hospital clinic where she suffered a cardiac arrest and sadly died that morning.

Wiltshire Safeguarding Adults Board

Local Learning Review - Adult E | published June 2019

At 67 years old, Adult E was described as jovial and determined and was generally quite active, although she had days when she did not want to engage with people. Adult E had a learning disability, epilepsy, osteoporosis and scoliosis and was cared for in a supported living property. With the help of a care provider she was able to live as independently as possible and managed relatively well. However, Adult E’s health began to decline and, in the last few months of her life, she was admitted to hospital on four occasions after fracturing her ankle, suffering from dehydration, having low food intake and reduced bowel movements. Adult E became less able to care for herself, even with support.

Following these four admissions, Adult E was admitted to RUH, discharged home and then readmitted following concerns that she was not eating, drinking or getting up from her seat. She was in RUH for just over a week before being discharged to Savernake Community Hospital. However, one day later, she was readmitted to GWH where she later died. The cause of death was Hospital-Acquired Pneumonia (HAP) with epilepsy, frailty and Learning Difficulties.

Teeswide Safeguarding Adults Board

Learning from Regional and National Cases | May 2019

These are excellent summaries. Read more.

Wiltshire Safeguarding Adults Board

SAR Learning Briefing 2019 | March 2019

Wiltshire SAB have produced a really useful learning briefing on the four reviews they have conducted in the last three years. The briefing brings together common themes including application of the Mental Capacity Act (2005), self-neglect, the effective application of safeguarding procedures, effective assessment, communication and difficulty engaging with service users. Practitioners are encouraged to read this briefing as these issues are pertinent to Norfolk.

Suffolk Safeguarding Adults Board

Mr B | published March 2019

Mr B, aged 61, who had mild learning disability, died in June 2017 from smoke inhalation duringa house firein the early hours of the morning. His friend Mr C, who lived with him, also died in the fire. The conditions in their home showed a pattern of extreme hoarding and severe neglect of cleanliness and hygiene.Mr B’s personal care was also severely neglected. They were well known to a number of services,who at the time of their death were pursuing a risk management plan under the safeguarding procedures of the Suffolk Safeguarding Adults Board.

Bromley Safeguarding Adults Board

Ms A | published March 2019

The Bromley Safeguarding Adults Board (SAB) commissioned the SAR (September 2018) to elicit learning from this case, which met the statutory SAR criteria set out in section 44 of the Care Act 2014. The Terms of Reference confirmed that the SAB wanted to explore the complex issues that practitioners engage with when working with adults who have a combination of serious physical health conditions, significant psychological presentations, and a history of resisting treatment and support. Ms A was assessed as having the mental capacity to make ‘unwise decisions’ about her care and treatment. The SAB wanted to understand what changes could be made to local systems to improve practice in relation to self-neglect in the future.  
Whilst living with her grandmother, Ms A died in 2017 at the age of 28 due to physical complications relating to Type 1 Diabetes and kidney disease. Records indicated that Ms A had shown some early signs of emotional distress as a child, and had been diagnosed with Diabetes Type 1 at age 15, but she had little contact with services until her early 20s when symptoms of depression, anxiety and bulimia emerged. The SAB focussed the attention of the SAR on the two years prior to Ms A’s death (May 2015 – May 2017) to keep the primary focus on looking at the way agencies work locally.

Solihull Safeguarding Adults Board

Rachel | published 30 January 2019

This Safeguarding Adults Review (SAR) was commissioned in May 2017 following the death of Rachel who was 20 years old. Rachel had previously been a victim of sexual abuse, and had a history of mental health difficulties and self-harming behaviours. She was also a victim of sexual exploitation and trafficking from the age of 17 onwards. Rachel was found dead in her bedroom at the supported accommodation where she had been living. The outcome of an inquest was the Coroner reaching a determination that the cause of death was drug related.

Stockport Safeguarding Adults Board

Elizabeth | published January 2019

Stockport Safeguarding Adults Board commissioned a safeguarding adults review regarding an adult, known as Elizabeth, who sustained fractures and bruising whilst living at home. Elizabeth was 87 years old. She lived in a one-bedroomed first floor flat and she had two sons who both spent extended periods of time living with her.

It was reported that from the injuries Elizabeth sustained, there was no medical treatment sought for 4-7 days, and since then, she had been in bed immobilised. There was previous concerns relating to financial exploitation, and the buzzer to Elizabeth’s flat had also been disconnected along with concerns of compliance with her medication.

Wiltshire Safeguarding Adults Board

Adult D | published December 2018

This review looks at the death of Adult D a 40 year male of no fixed abode who was alcohol dependent. Adult D had presented to a Hospital Emergency Department in the South of England in early 2017, reporting symptoms of alcohol withdrawal.

He was advised to continue drinking on discharge, to avoid withdrawal, until he could access support. A few days later whilst travelling through Wiltshire, Adult D was asked to leave a train when it stopped at a local station after he was found to be heavily intoxicated and unable to produce a ticket. In the early hours of the following morning, police were called to a nearby block of flats where Adult D had gained access to a communal area.

Officers had difficulty communicating with Adult D, who appeared to speak little English and he was heavily intoxicated. Officers called an ambulance and paramedics attended. Physical checks were not carried out by the paramedics and Adult D was not taken to hospital. Adult D was left with police officers who then took Adult D to a local public toilet block, in which they believed he had indicated he was content to shelter overnight. Adult D was found, deceased, the following morning in the toilet block. 

A Coroner’s Inquest found that Adult D’s death was caused by acute alcohol intoxication and hypothermia.

Oxfordshire Safeguarding Adults Board

Adult C | published April 2018

Adult C had a long history of involvement with the police and had some recent involvement with mental health services at the point of his death. The report found it unlikely that there was anything agencies could have done to predict or prevent the explosion that took Adult C’s life. There are some actions identified by individual agencies and the report author and Oxfordshire Safeguarding Adults Board did not feel there was anything more to be added in terms of multi-agency considerations.

Kent and Medway Safeguarding Adults Board 

Mrs Beryl Simpson | published January 2018

Beryl Simpson (not her real name), aged 82 years, lived with her daughter aged 62 years, in a house that Beryl owned in Town A, Kent. On 6 December 2016, following concerns raised by Kent County Council Adult Social Care & Health about Beryl’s welfare, officers from Kent police used their power under Section 17 of the Police and Criminal Evidence Act 1984 to enter the house. 

They found Beryl in a very poor state of health; she was emaciated and malnourished. Her daughter was also present in the house, which was in poor repair. There was no working toilet, it was cold and there was evidence of long term extreme hoarding. After Beryl’s condition was stabilised by paramedics, she was taken to hospital. Despite intensive treatment she failed to thrive and died in hospital on 15 December 2016.

Buckinghamshire Safeguarding Adults Board

Ms T