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SAR - Mr AA (Published November 2015)

The Norfolk Safeguarding Adults Board (NSAB) has today (11th November 2015) published a Safeguarding Adults Review into the death of a man who lived with mental health problems.This is a very sad death and our thoughts are with the family who have lost a loved one. This was a joint review with Suffolk Safeguarding Adults Board and both Independent Chairs wish to record their condolences and thank the family for their assistance throughout the process. 

Under the provisions of the Care Act 2014, all Safeguarding Adults Boards (SABs) are required to undertake a Safeguarding Adults Review (SAR), overseen by an Independent Report Writer, in order to learn lessons and improve practice when a situation arises with a person in their area who requires care and support, where doubts have been raised about the quality of service they received and deserved. The key aim of the SAR is not to investigate or apportion blame, but to examine professional practice and adjust this practice in light of lessons learnt. These lessons are vital to reduce the risk of re-occurrence.

Mr. AA was a Norfolk resident, aged 42 years. He was diagnosed as living with paranoid schizophrenia and had received mental health services over a long period of time. At the beginning of 2014 he went into a period of decline and died in a Suffolk hospital in January 2014. The cause of death was bronchopneumonia, but concerns were raised about the intervention he received up until the time of his death. As a result a SAR was commissioned, in partnership with Suffolk SAB, and the report and learning action plan are published here and on Suffolk Safeguarding Adults Board website.

SAR Mr AA Final Report 30-09-2015

SAR Mr AA Action Plan [09] / Updated 23-03-2017