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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.

Teeswide Safeguarding Adults Board (TSAB) 

Thematic Analysis of SARs involving Cross Boundary Issues | April 2024

The Teeswide Safeguarding Adults Board (TSAB) has seen an increase in the last two reporting years of SARs that cross geographical boundaries involving multiple SABs.

TSAB have completed a piece of work to look at learning from SARs nationally, that includes cross boundary issues.

This report reflects on 13 SARs – please feel free to circulate as appropriate amongst your own networks:

Thematic Analysis of SARs involving Cross Boundary Issues

Surrey Safeguarding Adults Board (SSAB)

Louise | published February 2024

This review considered the following specific issues.

  • Management of incidents of Domestic Abuse with someone who may be seen as a victim rather than a perpetrator
  • Information sharing in relation to mental health provisions
  • Risk assessment and management of the risk of suicide for adults prior to discharge from formal hospital admission, following a suspected suicide attempt
  • Decision making in relation to capacity and involving the family in the process.
  • Including the family within Care Act Assessments.

On the 31/03/2021 Louise was discovered by Surrey Police to have died at home, with some evidence to suspect that this was caused by an overdose of medication. She had been known to mental health services and had recently been discharged from a psychiatric hospital admission under S2 (MHA ’83) (25/03/2021) less than a week before she died.

This hospital admission arose following a previous overdose attempt on 23/02/2021, whereby her son found her at home and called an ambulance, leading to her hospital admission in Epsom, initially to the High Dependency Unit and subsequently to her transfer to psychiatric hospital for her final admission on 04/03/2021.

Louise had been in a relationship for over 10 years with a man whom she lived with (Tom), she had a son (Owen) and daughter (Elaine) from a previous relationship, while Tom had a daughter. Tom had suffered a stroke 2 years previously and Louise reported his behaviour had changed since this time. Louise had made some allegations about domestic abuse from Tom, but these were disputed by both her children and his daughter. She was referred by the police to both Adult Services and subsequently to MARAC and local domestic abuse services following these allegations.

Tom had been arrested and bailed with conditions not to return to the family home. Louise had previously been referred for both counselling and medication by her GP for depression and stress. Louise had also identified a legal dispute with tenants of a flat she owned as a significant cause of stress for her, which she was struggling with.

The SAR makes 9 recommendations.

You can read the executive summary and full reports here.

Torbay and Devon Safeguarding Adults Partnership (TDSAP)

Stephen | published January 2024

This Safeguarding Adults Review (SAR) was commissioned to learn from the circumstances surrounding the death of Stephen in December 2020. Stephen’s body was found at his home on the 17th December 2020. A 42-year-old male and 32-year-old female were subsequently found guilty of his murder. They are described in press reports being under the influence of both alcohol and heroin when they murdered Stephen. They appear to have known him for a short period of time before murdering him.

Stephen was a 60-year-old man of white UK heritage who lived alone in a property left to him in trust after his father died. He was described as having a ‘mild to moderate’ learning disability. In court reports regarding his murder he was also referred to as a person with autism, although he had never been diagnosed.

Read the executive summary report here.

Bexley Safeguarding Adults Board

Thematic Safeguarding Adults Review on Self-Neglect | published 06 November 2023

Read the thematic review here.

Croydon Safeguarding Adults Board

'Ben' | published 05 September 2023

Ben was 39 years old and known to social services when he died. He was well-educated and was active in local politics.

This SAR raised issues around self-neglect, mental capacity and executive function, information-sharing and discharge to “no service”.

Ben was brought to the attention of social care and health services by his friends, who were concerned that he was neglecting himself. Ben initially said that he would accept help from social and mental health services, but then cancelled or did not attend appointments. Ben had also provided false contact details to services.

Following concerns from friends, the police forced entry into Ben’s home. Ben was found in a state of self-neglect and hoarding.

Ben was admitted to hospital where it was found that he had several health conditions associated with prolonged extensive use of alcohol. There was hope initially that Ben would recover, but his condition deteriorated and he died in hospital. Ben’s cause of death was hepatic encephalopathy, a neuropsychiatric syndrome caused by liver failure.

Read the full report and the 7 Minute Briefing here.

Milton Keynes Together Safeguarding Partnership

Thematic review on Self-Neglect, Fire Safety and Alcohol Dependency

This review was commissioned following the death of two adults in separate unconnected incidents. For the purposes of anonymity, they are known within this review as ‘Charles’ and ‘Dylan’. Both men were white British. Charles was in his early 70s whilst Dylan was in his early 50s. Both had experienced alcohol abuse for many years. Both adults were known to services, and it was understood they could be at risk of harm from poor management of their health, personal care and long-standing alcohol abuse. They both lived alone, though did have family members who were seen by practitioners as ‘protective factors’.

Prior to the commissioning of this review, the circumstances surrounding Charles’ death had been subject to an internal serious incident review by Buckingham Fire and Rescue Service and an inquest. These concluded he died in an accidental fire, likely started when a cigarette ignited his bedding and accelerated by lighter fuel3 and alcohol on his bed. There was no inquest into Dylan’s death as it was determined that he died of natural causes.

Safeguarding Adults Thematic Review (Dylan and Charles) Report

Safeguarding Adults Executive Board (SAEB)

Fatal Fire Thematic | published 09 August 2023

Over the course of 2020 the SAEB were notified of several fire deaths across the Bi-Borough, which led to a series of improvement actions being undertaken. In response to two further fire death notifications in 2021, the SAEB commissioned Independent Reviewers Professors Michael Preston-Shoot and Suzy Braye to undertake a thematic review. As well as exploring the individual circumstances of the two cases the review adopted a broader approach to consider how well fire action improvement actions already undertaken had become embedded in practice.

The two cases which have been anonymised in the report are referred to as Mr C and Mr D.

Mr C was an 85-year-old man who lived in an extra care housing scheme who died following a fire in his flat which was likely to have been caused by dropping a match whilst smoking.

Mr D died at the age of 61 following a fire in his privately rented flat, in which the most probable cause of the fire was unsafe use or disposal of smoking materials whilst in bed. Both men had experienced a decline in their physical functioning in the recent months prior to their deaths.

The Learning Briefing sets out:

  • The Findings
  • What we are doing to respond to the learning
  • Key points for reflection

The full report and learning briefing are available on the website here: Published SARs - Safeguarding Adults Executive Board

Torbay and Devon Safeguarding Adults Partnership

Devon Multi Agency Systems Review | published 18 July 2023

The Devon Multi Agency Systems Review identifies the learning following five homicides in Devon, between 2018-2019. This report has a focus on mental health care and management in custody. Primary focus of this review is on the learning from three homicides that occurred in 2019 by the same individual, referred to as Mr A.

Although Mr A met the criteria for a Safeguarding Adults Review (SAR), it was decided that a multi-agency systems review, led by NHS England and Improvement (NHSE), would be the most appropriate methodology to uncover the systems learning.

You can read the Multi Agency Systems Review here.

Kent and Medway Safeguarding Adults Board

‘Rosie’ and ‘Emma’ | published 19 July 2023

Both girls were known to services, had been looked after as children, and were in contact with several agencies including the local authority, NHS and Social Care Partnership Trust, police and homeless charities. Both Rosie and Emma had mental ill health and had attempted suicide before they died.

You can read the overview report here.

Haringey Safeguarding Adults Board

Steve | published July 2023

Steve was a man who lived alone in poor conditions in privately rented accommodation for which he received housing benefit. In mid-March 2020, Steve is reported to have injured his leg falling through the rotten floor in his property. Steve died in hospital on 23rd March 2020, aged 61 years, following leg amputation. 

Steve had complex health needs, including Type 2 Diabetes, depression and deep vein thrombosis. He had suffered falls and was reported to be at risk of being re-admitted to hospital due to this.

Steve was described by those supporting him as a gentle, calm man. He very much wanted to engage with those who were supporting and caring for him. He took a pride in himself and in his appearance, despite the difficulties in his living situation. He was clearly liked by those who supported and cared for him. He was embarrassed by his personal circumstances and was therefore often reluctant to talk about them and to allow visits to his home.

Steve’s brother also explained that Steve would not allow him or Steve’s son into his home, even on occasions where he had brought financial assistance to Steve. His brother explained that Steve had a history of alcohol misuse and he believed that this was at the root of many of Steve’s problems.

Changes and improvements have already been made by the agencies involved in this review, but the Safeguarding Adults Review has recommended further improvements regarding:

  • Reviewing the use, accessibility and promotion of multi-agency meetings
  • The processes available to escalate concerns about private sector housing
  • Provision of regular adult safeguarding training widely across agencies
  • Review and promotion of adult safeguarding pathways
  • Oversight and follow up of referrals to alcohol and mental health support services
  • The housing needs assessment of vulnerable people.

You can read the full report here.

Cornwall and Isles of Scilly Safeguarding Adults Board

CT | published 27 June 2023

A Safeguarding Adult Review, carried out following the death of a 64-year-old man having suffered significant burns and smoke inhalation during a fire at his home address.

You can read the SAR for CT Executive summary here.

Salford Safeguarding Adults Board

ET | published June 2023

ET was diagnosed in 2017 with Alzheimer’s, family described it as a slow decline. Her family supported her for many years. Her daughter was made redundant in 2021 and started to spend more time with her, and it was during this time, the family started to realise that she was struggling with some daily living tasks.

When her daughter found new employment, the family approached Adult Social Care to request an assessment with a view of getting some formal support in place. Unfortunately, a package of support couldn’t be commissioned in time, and emergency respite was offered in the form of a care home placement.

Within her first 24 hours of in the care home she had an unwitnessed fall which resulted in a hospital admission. After several weeks in hospital, she was discharged back to the care home where there was a number of safeguarding incidents including ET being inappropriately touch by another male resident on different occasions. The fall resulted in ET staying in the care home for a longer period. ET was never able to return home and passed away with her family around her in the care home.

Review themes include:

  • Capacity in the care market
  • Hospital admission/discharge
  • Therapeutic support/rehabilitation
  • Sexual assault
  • Safeguarding – management S42 enquiries
  • Deprivation of Liberty (DOLS)
  • End of life care

You can read the overview report here.

Nottingham City Safeguarding Adults Board

Billy | published May 2023

This Safeguarding Adult Review (SAR) relates to a man ‘Billy’ who died from starvation in 2018. Billy was a single man in his fifties of Black African Caribbean heritage, who lived alone in his flat as a tenant of Nottingham City Homes (NCH).

Eight months before his death, the Department for Work and Pensions (DWP) had stopped Billy’s Employment Support Allowance (ESA) as Billy had not responded to requirements to review his entitlement. When his ESA ended, this meant his Housing Benefit was not paid. Billy quickly fell into arrears. Billy did not respond to NCH attempts to resolve this.

At the time of his death, Billy was at point of eviction, his gas supply had been cut off, so he had no heating or hot water, and he had no income for basic essentials of food and utilities. Billy had struggled for many years with his mental health as well as problems with an under-active thyroid. He had been diagnosed with depression and had been treated by his GP on anti-depressant medication for many years. Billy had a son, daughter-in-law and grandchildren who were very supportive of him, but Billy was very independent, kept to himself and declined help.

Learning points include opportunities for early intervention to support Billy’s mental health, interactions by agencies leading up to Billy’s death. The review makes 5 recommendations.

Read the full report here.

Valentina | published May 2023

This Safeguarding Adult Review (SAR) explores the sad circumstances of Valentina’s death. Valentina had mental health needs; she had a diagnosis of Emotionally Unstable Personality Disorder and physical health needs due to her diabetes. Valentina died in 2019, having taken a deliberate overdose of her insulin. At the time of taking the overdose, Valentina felt overwhelmed by stressful life events.

Valentina had been the victim of sustained domestic abuse from her ex-partner. In the months leading up to her death,
Valentina had also been attempting to claim Personal Independence Payment (PIP) through the Department for Work and Pensions (DWP). Problems within this process caused her extreme anxiety and distress. This additional stress significantly increased her risk of self-harm and suicide.

Valentina received a high level of support from her family and from agencies. The Nottingham City Safeguarding Adult Board (NCSAB) believed that there was learning about how agencies had worked together in relation to supporting Valentina and reducing the risks of harm arising from stressful events.

Section 6.4 of the report looks at agencies’ responses to financial stress and sets out what has changed since Valentina's death including important changes at the DWP (see 7.2) 

Read the full report here.

Croydon Safeguarding Adult Board (CSAB), in collaboration with Bromley Safeguarding Adults Board (BSAB) and Kingston Safeguarding Adult Board (KSAB)

Sylvia | published 04 May 2023

This SAR was commissioned after Sylvia was tragically found dead in September 2021, of a suspected drug overdose.

Sylvia was a 19-year-old British Sri Lankan woman who was known for her smile, charm, love of dancing, and artistic expression. Her youth worker described her as a "beautiful soul" and provided support to her throughout her youth.

Sylvia and her siblings became known to Kingston’s Children’s Social Care in 2007 due to concerns about her lack of education since age 11, exploitation, drug use, and missing episodes. Despite a care order in 2016, suitable placements were difficult to find, leading to frequent moves and a stay in a specialist unit for young people at risk of child sexual exploitation.

Key themes and learning points include:

  • education and early intervention
  • response to exploitation
  • discharge planning and S117 aftercare 
  • transition to adulthood
  • understanding the legal and policy frameworks and managing multiple risks
  • S17 leave and risk management

Read the full report and 7 minute briefing here.

Teeswide Safeguarding Adults Board (TSAB)

Thematic Analysis of SARs Involving Adult Sexual Exploitation | April 2023

Blackpool Safeguarding Adults Board

Jessica (Adult V) | published 4 April 2023

Jessica was born with Down’s Syndrome. As Jessica developed, her level of independence was established; she was independently mobile but required someone with her to access the community. Jessica lacked capacity for many of her decisions but was able to make basic choices when offered options from things she knew and had experience of.

Jessica was dependent on others for her meals and the provision of a clean and tidy home environment. Jessica lived with her mother (Ann) and siblings. When Jessica was 18 years old, Ann moved Jessica from East Sussex to Leeds. In 2016 when Jessica was 21 years old, the family moved to the Blackpool area.

Jessica died at home, aged 24 years as a result of severe emaciation and neglect and widespread and severe scabies infection. There was no evidence of Jessica’s hygiene or personal needs having been met for a considerable length of time. Following Lancashire Constabulary commencing a criminal investigation, Jessica’s mother pleaded guilty to gross negligence manslaughter and was sentenced to 9 years and 7 months imprisonment.

The focus of the Safeguarding Adult Review was the circumstances surrounding Jessica’s deterioration and death. Key themes and learning points include:

  • transference of information across borders
  • referrals
  • whole family approach
  • carer abuse
  • Jessica's voice

You can read the learning brief and overview report here.

East Riding Safeguarding Adults Board

Learning Brief - Physical Abuse in a Care Home | published 03 March 2023

This Learning Brief relates to an elderly lady living in a residential home. Following feeling unwell she was taken to hospital and found to have a malpositioned urethral catheter which caused her kidneys to block and sepsis to develop The resident died the day after admission to hospital with cause of death as Urosepsis, malposition of catheter and frailty.

The case was referred for a SAR but it was decided that a Learning Brief would be created to cascade the lessons learned.

Read the Learning Brief - Physical Abuse in a Care Home here.

Worcestershire Safeguarding Partnership

Dorothy | published March 2023

Dorothy was a 77-year-old lady who had severe dementia and her daughter had found it increasingly difficult to ensure she had the support she required to continue living at home. After 5 weeks in hospital, Dorothy was placed in the care home.

Following an altercation with another resident Dorothy fell and was taken to hospital. During the journey to hospital Dorothy deteriorated and died 10 days later in hospital. A safeguarding alert was raised regarding the incident. Concerns were raised regarding the suitability of the care home to manage residents with challenging behaviours. Dorothy was CHC funded (under Covid discharge scheme), and the other resident was self-funded. Both had only recently moved to the care home following completed assessments.

Learning identified includes

  • assessment and placement
  • resident on resident abuse and harm
  • caring for carers

You can read more here: Worcestershire SARs.

Bromley Safeguarding Adults Board 

Catherine | published February 2023

Catherine is an older woman and lived with her husband, who was her informal carer. She had complex health
needs, including diabetes and newly acquired blindness. Police and London Ambulance Service attended Catherine's home where she was found with serious stab wounds to her chest inflicted by her husband, who had also stabbed himself. She had seven hospital admissions in the previous 2 years and received home visits from community health and social care services daily.

The review's findings include

  • identified good practices that include appropriate referrals and communication between agencies, as well as completing relevant assessments
  • Information available to practitioners provided few indications that Ms C may be at risk of serious harm from her husband, a point endorsed fully by Ms C herself, family, and friends
  • The assessment and offers of services were deemed appropriate, and the couple was resistant to further support
  • Although there is no evidence of domestic abuse occurring during their long marriage, there were
    missed opportunities to investigate potential signs of abuse in the case of Ms C and Mr D
  • Some practitioners may potentially be missing signs of abuse in older people by not asking the right questions, and need to understand that the dynamics of domestic abuse of older people differ from those of younger people.

You can read the 7 Minute Briefing, full report, and an easy read summary here which outlines the themes, learning and recommendations from this Safeguarding Adults Review.

Bi-Borough Safeguarding Adults Executive Board (SAEB) on behalf of Kensington and Chelsea

Joan | published November 2022

Joan who passed away at the age of 88 after experiencing a significant and rapid decline in her health over the last year of her life.

The review highlighted key learning around:

  • Multi-agency communication and coordination
  • The importance of ensuring that reasonable adjustments are provided to support person-centred care
  • The understanding and application of the Mental Capacity Act
  • Working effectively with families who are expressing concerns about quality of care.

SAEB launched Joan’s Legacy Video, in which Joan’s Granddaughter, Lesley offers powerful insights regarding Joan’s and her family’s experiences, making a valuable contribution that supports the legacy of learning from Joan’s story.

You can read the learning briefing and the full report here.

Lewisham Safeguarding Adults Board

Eileen | published 11 November 2022

Eileen Dean was a 93-year-old white British woman who had moved into a care home in Lewisham in June 2020. Eileen led a full and independent life until she developed dementia which ultimately curtailed her interests. Although her capabilities were reduced by dementia, Eileen remained happy and contented.

Eileen was killed in the care home by another resident.

You can read the 7 Minute Briefing and the full report here which outlines the themes, learning and recommendations from this Safeguarding Adults Review.

Teeswide Safeguarding Adults Board (TSAB)

Molly | published June 2022

Molly was 25 years old and was known to multiple agencies. Molly was a victim of child abuse and there were concerns about domestic abuse in her adult life. There were also concerns around Self-Neglect, homelessness, self-harm, substance misuse and sexual exploitation by multiple perpetrators. The Review highlighted lots of good practice and multi-agency working, however professionals were frustrated and saddened that despite their best efforts to protect Molly, they felt powerless to prevent such a tragic outcome.

“Professionals had done what they could but that the door was shut and the men (and women) who were controlling her, supplying drugs and abusing her were never brought to justice” – Molly’s mum

The Independent Reviewer of Molly’s report highlighted that nationally there is very little research, policy, procedures, or guidance around Adult Sexual Exploitation (ASE) and guidance around exploitation is very much focused on children.

The Review recommended for TSAB to understand what other SABs have experienced in relation to ASE cases to identify good practice and learning, to pick up on any elements that are relevant to TSAB.

Thank you to colleagues who shared their SAR Reports with me for the purpose of this analysis and research.

A number of key themes/learning points were identified:

  • Lack of Adult Sexual Exploitation Guidance for practitioners
  • Multi-agency approach to prevention / protecting victims and disrupting perpetrators
  • Strategic oversight of complex cases
  • Understanding trauma and the impact of coercion
  • Support for staff and vicarious trauma
  • Transition
  • Engagement
  • Criminal justice issues and victim blaming
  • Legal Literacy and consent
  • Lack of appropriate accommodation / specialist support

The cases that were reviewed all involved young women (or girls), many of whom died. TSAB are keen to raise the profile of ASE on a national basis and hope that this report supports you with ongoing discussions in your area so that we can all help to prevent unnecessary and untimely deaths.

Although the recommendations are from a Teesside perspective, the report may be of use to other Safeguarding Adults Boards to consider

Molly - Safeguarding Adults Review Report.

Thematic Analysis of SARs Involving Adult Sexual Exploitation (published April 2023).

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 full SAR report and learning briefing on their SARs page, outlining the themes, learning and recommendations from this Safeguarding Adults Review. Cumbria SAB SARs

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.

Calderdale Safeguarding Adults Board

Burnt Bridges? A Thematic Review of the deaths of five men on the streets of Halifax during Winter 2018/19 | published December 2020

‘Burnt Bridges’ thematic review into the lives of five men who lived street based lives is seen as the single most impactful Calderdale have ever undertaken.

The different links are: the full report, a 7 minute briefing, a video of the 7 minute briefing, the Safeguarding Adult Board Response and an event recording of a learning event.

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

Full SAR here on the Cumbria SAB SAR page

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