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Further Information

SARs published by other Safeguarding Adult Boards

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

Click here for Lincolnshire SAB.

Click here for Teeswide Safeguarding Adults Board.


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.

Click here to download the full report.


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.

Click here to download the full report, exceuctive summary & 7 Minute Briefing.


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.

Click here for Local Learning Review - Adult E


Teeswide Safeguarding Adults Board

Learning from Regional and National Cases | May 2019

These are excellent summaries. Click here to 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.

Click here for Wiltshire SAB SAR Learning Briefing 2019


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.

Click here for the Safeguarding Adults Review - Mr B | published March 2019


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.

Click here to download the SAR Executive Summary.


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.

Click here to download the report.


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.

Click here to read the full report.


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.

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


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.

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 | 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.

Click here for a summary and the SAR recommendations.


Buckinghamshire Safeguarding Adults Board

Ms T Overview Report and Executive Summary (August 2017)