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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.


Cumbria Safeguarding Adults Board

Kate | published 29 June 2022

Cumbria SAB have published a SAR learning report is published following the death of a young woman known as Kate who sadly died in 2020, aged 18 years old. The cause of Kate's death was established as being drug related.

Services had been involved with Kate and her family since 2018, when it was identified that she was at risk of child exploitation.

Unfortunately, Kate’s situation, including her vulnerability did not improve, and she sadly died in 2020.

The Safeguarding Adults Review identified the following learning themes;

  • Raising awareness of the impact of exploitation
  • Processes to protect children from exploitation
  • Response to young adult victims of exploitation
  • Use of the National Referral Mechanism (NRM)
  • Response to homelessness
  • Issues around engagement

You can read the Learning Briefing Report here which outlines the themes, learning and recommendations from this Safeguarding Adults Review.


Cumbria Safeguarding Adults Board

Pauline & George | published 20 May 2022

This Safeguarding Adult Review (SAR) concerning the events and multi-agency working prior to the sad death of a married couple known as Pauline & George.

Pauline and George lived together in their own home. Pauline had care and support needs due to mobility difficulties following a stroke and although she could manage some tasks, she was very reliant on George as her carer for many aspects of day-to-day living. Pauline experienced a number of falls which towards the end of her life had increased in frequency. However, the couple consistently declined any support.

George had his own health needs and when he missed an outpatient appointment, a GP made a home visit where sadly, Pauline and George were both found to have died some time previously.

The Safeguarding Adults Review identified the following learning themes;

  • Building relationships and working with resistance to care
  • Working with risk
  • Working across agencies and communities
  • Strategic responses to self neglect

You can read the SAR Report in full here or the supporting Learning Brief here which outlines the themes, learning and recommendations from this Safeguarding Adults Review.


Cumbria Safeguarding Adults Board

Mr X | published 13 December 2021

Cumbria Safeguarding Adults Board have published a Safeguarding Adult Review (SAR) concerning the care and treatment of a 93-year-old man referred to as ‘Mr X’.

Mr X was admitted to hospital in August 2018 for medical tests when his health deteriorated. Whilst in a hospital, Mr X made a number of disclosures of physical and sexual abuse to health and social care staff which were not responded to in a timely way following the appropriate procedures. The system learning includes:

  • There was a lack of clarity in procedure and practice when managing parallel safeguarding adults’ enquiries, police investigations and human resource procedures
  • Frontline staff are not familiar with the multi-agency guidance
  • Staff did not use the systems and procedures in place for responding, recording, and escalating safeguarding adults’ concerns

Read the full report (8 pages) here. A Learning Briefing is also available which outlines the themes and key learning from the circumstances of the Safeguarding Adults Review.


Sunderland Safeguarding Adults Board

Alan | published August 2021

Alan was a 53 year-old man who died as a result of an accident with a fire caused by a cigarette in a garage where he was sleeping for the night. Alan had a pattern of involvement with health, social care and criminal justice services throughout his adult life. This was underpinned by his chronic alcohol dependency, with Alan having begun drinking at 15 years of age. He lived a chaotic lifestyle and at the time of his death Alan was homeless and subject to statutory safeguarding, though sadly he died before any meaningful safeguarding work was undertaken.

Key learning focusses on:

  • specific needs and impacts of chronic, change resistant and dependent drinkers
  • the role of brain injury as a driver of presentation of people like Alan needs to be recognised by professionals; particularly in the context of mental capacity assessment
  • role for assertive outreach with the most challenging chronic dependent drinkers
  • how the Mental Capacity Act applies to chronic dependent drinkers

SAR Report & 7 Minute Briefing


Essex Safeguarding Adults Board

'Leanne' | published May 2021

This report outlines the Safeguarding Adults Review into the period of care prior to Leanne's death.  Leanne died in March 2018, aged 25.  Leanne had been adopted aged approximately four years old and had been known to mental health services from age 16.  She moved out of the family home when she was 18 and it was then that she became unwell.  She was self-harming and was also known to the eating disorders service.  Following her GCSEs and A 'levels, she had applied to study maths at university.

An inpatient need for care was identified in 2016.  Staff reported her as being bright in mood but chaotic, with a desire to write things down and need to be in control.  She absconded three times, returning once of her own volition.  At the time of her death she was living in supported accommodation.  Her last contact with her GP was three months before she died, where she presented frail with a persistent cough.  

SAR report for Leanne


Cornwall and Isles of Scilly Safeguarding Adults Board and the Safer Cornwall partnership 

'Margaret' | published 26 January 2021

This is a joint Domestic Homicide Review (DHR) / Safeguarding Adults Review 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

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

In September 2019, Worcestershire Safeguarding 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.


Luton Safeguarding Adults Board

Abdullah | published September 2020

This review focuses on a man who is originally from Somalia, a 47 year-old man who died in May 2018. He was found
at home in his flat. He lived in a housing scheme which offered some on-site support. This review highlights the cross-cultural impact of alcohol.


Lewisham Safeguarding Adults Board 

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 Safeguarding Adults Board

'Robyn' | published 9 June 2020

Robyn (an 85 year old female) 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 carers
  • resolving professional disagreement
  • coercive control
  • NHS Continuing healthcare

Learning Brief and full report


North Lincolnshire Safeguarding Adults Board 

Adult A | published 27 May 2020

Adult A was an 87 year old male 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 

Adult B | published February 2020

In February 2020 the East Sussex SAB published the findings of a Safeguarding Adult Review after the death of a 94 year old female 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 Safeguarding Adults Board

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 five times a day from two 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 two 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 9 March 2017 her 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 two 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 Royal United Hospital (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. One day later, she was readmitted to Great Western Hospital where she later died. The cause of death was hospital-acquired pneumonia 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 Partnership

Mr B | published March 2019

Mr B, aged 61, who had mild learning disability, died in June 2017 from smoke inhalation during a house fire in 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 Partnership.


Bromley Safeguarding Adults Board

Ms A | published March 2019

The Bromley Safeguarding Adults Board 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 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 between four and seven days, and since then, she had been in bed immobilised. There were 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.


Buckinghamshire Safeguarding Adults Board

Ms T