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Further Information

SARs published by other Safeguarding Adult Boards

Wiltshire Safeguarding Adults Board

Safeguarding Adults Review - Adult D | Learning Briefing

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.

Click here for the Safeguarding Adults Review - Adult D | Learning Briefing.


Oxfordshire Safeguarding Adults Board

Adult C (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.

Click here for Safeguarding Adult Review Adult C – Full Report (published April 2018)

Click here for Safeguarding Adult Review Adult C – Statement (published April 2018)

Click here for Oxfordshire SAB's Case Reviews page


Kent and Medway Safeguarding Adults Board 

Mrs Beryl Simpson (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.

Click here for a summary and the SAR recommendations.


Buckinghamshire Safeguarding Adults Board

Ms T Overview Report and Executive Summary (August 2017)