Safeguarding Adults Reviews
The Board is required to commission Safeguarding Adults Reviews (SARs) for any cases meeting the criteria for these. The Care Act 2014 introduced SARs, which were previously known as Serious Case Reviews.
Listed below are reviews commissioned and published by the Safeguarding Adults Board.
It is not currently a statutory requirement to publish reports; however, it is recognised good practice to demonstrate the level of transparency and accountability needed to enable lessons to be learned as widely and thoroughly as possible. It is therefore our policy that all reports are published in full unless:
- publication could be deemed to be detrimental to the person’s well-being or
- the person, or their family member(s) who act/acted in the person’s best interests, ask for the report not to be published
Where a report is not published for these reasons we will produce a practice briefing containing learning identified to ensure professionals are able to understand what happened and, crucially, what needs to change in order to reduce the risk of similar tragic events happening in the future.
Published reviews
Safeguarding Adults Review: ‘Family W’ (2024)
Safeguarding Adults Review: ‘Peter’ (2024)
Safeguarding Adults Review: ‘Robert’ (2023)
A Safeguarding Adults Review was commissioned in to the death of ‘Robert’ (pseudonym), who had a history of self-neglect and died from respiratory distress and pneumonia. Organisations were attempting to support him in relation to his history of neglecting his own health and well-being and highlights the difficulties organisations face in supporting people with complex health and social care needs.
Safeguarding Adults Review: ‘Susan’ (2022)
A Safeguarding Adults Review was commissioned in to the death of ‘Susan’ (pseudonym), had a significant health condition that required daily medication, and concerns were identified with the way organisations worked together to safeguard her.
Practice briefing: ‘Mrs L’ (2022)
In this case a Safeguarding Adults Review (SAR) was not commissioned as it was determined that Mrs L’s case did not meet the criteria for a SAR. However, it was agreed to instead undertake a review of Mrs L’s case to determine what, if anything, the organisations involved might have done differently when she moved between two care homes and to develop a practice briefing based on this.
Death Review: ‘Kathleen’ (2022)
Following referrals to both the Safer Somerset Partnership and SSAB that did not meet the criteria for either a Domestic Homicide Review or a Safeguarding Adults Review, it was agreed that it would still be beneficial for an independently chaired review to take place to explore the learning for how agencies worked together for a period of approximately six years prior to Kathleen’s (pseudonym) death.
This was due to initial fact-finding identifying extensive involvement by many agencies related to domestic abuse and vulnerability.
The final report will not be published. However, a one-page briefing has been produced which identifies the key learning from the case.
Safeguarding Adults Review: ‘Matthew’ (2021)
A Safeguarding Adults Review was commissioned into the death of ‘Matthew’ (pseudonym), who had a history of multiple and complex health problems, including substance misuse, type two diabetes, chronic obstructive pulmonary disease (COPD) and skin infections.
Prior to his death, organisations were attempting to support him in relation to his history of neglecting his own health and well-being. Matthew’s case highlights the difficulties organisations face in supporting people with complex health and social care needs, who want to maintain their independence and decision-making.
Safeguarding Adults Review: ‘Damien’ (2021)
An extension to a Safeguarding Adults Review originally commissioned in 2015 was commissioned following new information emerging during an inquest in 2018. The original Review was not published in full, although a Practice Briefing Note was produced (see below). This will be revised based on the learning identified in this extension.
Damien had diagnoses of Asperger’s Syndrome and Attention Deficit Hyperactivity Disorder (ADHD). He had a learning difficulty, misused a variety of substances, and his vulnerability was exploited by others who stole from him and misused his home for their own purposes. Trying to meet the dual requirements of protecting both the public and Damien from harm, at the same time as allowing him to live his own life with as few restrictions as possible, tested services in Somerset. Damien died in hospital in July 2015 and had been discharged from an acute mental health ward to a residential care home two weeks prior to his death. In the last fifteen months of his life, he was detained under Section 2 of the Mental Health Act on three occasions.
Safeguarding Adults Review: ‘Luke’ (2020)
A Safeguarding Adults Review was commissioned into the long-term deterioration of Luke (pseudonym), a resident in a Somerset care home. Luke, aged 67 at the time of his death, had been a resident in the care home for about 18 months and had had a long history of neglecting his own health and well-being before he moved there. Luke had experienced a number of traumatic events in his life and, although Luke died from a diabetic foot ulcer, the focus of the report surrounds how agencies worked together in their approach to Luke and concerns about his mental capacity and neglect of his own wellbeing.
Practice briefing: Kevin (2019)
In this case, a Safeguarding Adults Review (SAR) was not commissioned as it was determined that Kevin’s case did not meet the criteria for a SAR. However, it was agreed to instead undertake a review of Kevin’s case to determine what, if anything, the relevant agencies and individuals involved in the case might have done differently. This was so that lessons could be learned from the case, and those lessons applied to future cases with the objective of avoiding similar circumstances reoccurring. These lessons are summarised in the Practice Briefing.
Kevin was middle-aged when he attempted to take his own life, shortly after the death of his partner, which had a life-changing impact on his health. Kevin had a history of very high-intensity contact with his GP surgery, with often multiple contacts per day, and the Emergency Department at his nearest hospital.
Alongside this Practice Briefing new guidance, entitled “What to do if it’s not Safeguarding“, has been developed for professionals and organisations on initiating multi-disciplinary discussions where someone does not require a Safeguarding intervention.
Safeguarding Adults Review: Mendip House (2018)
A Safeguarding Adults Review was commissioned by the SSAB following a whole service safeguarding enquiry into allegations of the mistreatment of residents living at Mendip House, a care home for adults with autism near Highbridge run by the National Autistic Society. None of the people living at Mendip House were Somerset residents; however, the review findings and recommendations include important learning for the commissioning and monitoring of out-of-area placements.
Thematic Review Of Serious Case Reviews And Safeguarding Adult Reviews: A Report For South West Region Safeguarding Adults Boards (2017)
This thematic review, undertaken by Professor Michael Preston-Shoot, forms part of the strategic priorities for 2017/18 set by South West regional adult safeguarding leads and South West ADASS. The thematic review undertook an analysis of the nature and content of 26 serious case reviews commissioned by Safeguarding Adults Boards in the South West region from 1st January 2013 up to the implementation of the Care Act 2014, and 11 safeguarding adult reviews commissioned and completed by Safeguarding Adults Boards in the South West region since the implementation of the Care Act 2014 on 1st April 2015, up to 31st July 2017.
Safeguarding Adults Review – Damien (2016)
Damien had diagnoses of Asperger’s Syndrome and ADHD. He had a mild learning disability and misused a variety of substances, causing him to come into frequent contact with the police and mental health services. His vulnerability was exploited by others who stole from him and misused his home for their own purposes. Meeting the dual requirements of protecting both the public and Damien from harm, at the same time as treating him as capacious and allowing him to live his own life with only the necessary oversight and control, testing services in Somerset. In the last fifteen months of his life, he was detained under Section 2 of the Mental Health Act on three occasions. He was also made subject to MAPPA arrangements. Damien died in hospital in July 2015 following an incident of self-strangulation in the residential unit that had been his home for two weeks following discharge. A Practice Briefing Sheet has been produced by the SSAB with support from Damien’s family, outlining the key considerations for practice that arise from the review.
Serious Case Review – Tom (June 2016)
A Serious Case Review was commissioned by the Somerset Safeguarding Adults Board (SSAB) following the death of ‘Tom’ who took his own life in 2014, aged 43. Tom had sustained a traumatic brain injury in a road traffic accident in his early twenties, which left him with physical, cognitive and psychological issues. In addition, Tom had a dependency on drugs and alcohol. The independent report published by the board today concludes that despite numerous contacts with many health and care professionals and the concerns of family members he was not provided with appropriate support.
A Practice Briefing Sheet was produced by the SSAB together with the author of the review in June 2016, outlining the key themes and findings to emerge from the review.
Case Debrief – Mr J (April 2016)
In April 2016, a multi-agency case debrief was convened to extract lessons learnt following the death of an elderly, terminally ill gentleman, Mr J. It highlighted issues around the effectiveness of safeguarding and hospital discharge procedures, challenges of working with resistant families/individuals and dealing with issues of self-neglect. Although a Safeguarding Adults Review was not commissioned, the Board publishes below, in the interests of shared learning, a Practice Briefing Sheet which extracts the key themes.
Serious Case Review – Ms C (February 2016)
In February 2016, the Board received the Serious Case Review of young woman with learning disabilities thought to have been the victim of domestic violence and sexual exploitation. A Practitioner Briefing Sheet has been produced by the SSAB’s Learning & Improvement Subgroup, outlining the key themes and findings to emerge from the review.
Learning Review into deaths of vulnerable young adults (June 2014)
Serious Case Review concerning Parkfields Care Home (May 2011)
This is the report of a Serious Case Review of the events at Parkfields Care Home that resulted in the conviction in April 2010 of the home’s registered manager for misappropriation of drugs, manslaughter and perverting the course of justice. Staff members had raised concerns in January 2007 that led to an extensive police investigation, which covered the care of ten older people than residents or formerly residents at the home, and Mrs Baker’s own medical care. The purpose of the Serious Case Review was to find out whether there were lessons to be learned about the way that professionals and agencies work together to safeguard adults in the period up to January 2007.
Hampshire Safeguarding Adults Board – Learning from Experience Database
Hampshire’s Safeguarding Adults Board has kindly agreed to the SSAB referencing its fantastic ‘Learning from Experience Database’ on our own website. The database contains links to national and local case reviews and aims to support the dissemination of learning, and in doing so promote evidence-based practice. The database allows visitors to filter case reviews by theme (such as mental health or self-neglect), year and local authority area.
Visit: Hampshire SAB