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Safeguarding Adult Reviews

The Care Act 2014 states that Safeguarding Adult Boards have a statutory responsibility to arrange a Safeguarding Adult Review (SAR) when an adult dies as a result of abuse or neglect (whether known or suspected), where there is concern that partner agencies could have worked more effectively together to protect the adult. The overall purpose of a SAR is to promote learning and improve practice. It is not to re-investigate or to apportion blame.

You can find each of the SARs and Learning Reviews published in the last 12 months below. SARs and Learning Reviews published prior to this can be found on the next page.

Safeguarding Adults Review in relation to Clare (February 2024)

Clare is 43 years-old and was born in Littlehampton with DiGeorge syndrome; a genetic condition that causes the underdevelopment of some systems in the body. Autism can also be associated with this syndrome, which was diagnosed in 2004. Her father, who contributed to the Review, described Clare as a quiet child with few friends, who was sadly bullied at school due to her disability. Clare also has a history of mental health concerns, including auditory hallucinations. Clare has lived in supported housing from around the age of 20, but at the time this Review was written, she was unwell and in hospital.

From February 2022, Clare began to express concerns about her mobility, due to long standing knee pain. Clare expressed that voices were telling her that her knee would break if she moved, which resulted in her remaining seated on her sofa for at least two weeks, leading to rapidly worsening hygiene circumstances. A Mental Health Act Assessment led to Clare’s admission to hospital. It was acknowledged that there were missed opportunities over many months for a robust multi-agency risk management meeting, to coordinate a comprehensive, personalised and holistic risk management plan to support Clare.

Key documents:

Safeguarding Adults Review in respect of John (December 2023)

John was an 88-year-old man, who was partially sighted and registered blind. After fracturing his hip in 2020, John required long-term care and was placed, initially temporarily, at Rotherlea Care Home. He also had some difficulties with his mental health over the years. John passed away in June 2022 at Rotherlea, after making the decision to end his own life, through refusal of foods and fluids.

It was acknowledged that there was learning for agencies involved with John, including professional curiosity, the determination of capacity, end-of-life care, and the care provided prior to John’s decision to end his life. This Review looks at the actions of involved agencies and made recommendations to improve practice to minimise future risk.

Key documents:

Safeguarding Adults Review in respect of DJT (December 2023)

DJT was a 49 year old Polish man who throughout his life experienced a number of traumatic life events. These events included the loss of his son at 21 years old, a subsequent end to his marriage, and an incident at work which resulted in sight loss. These life events caused DJT to become dependent on alcohol, which led to him making ‘unwise’ choices and self-neglecting in areas including his personal hygiene, nutrition, and financial responsibility.

Our review has found six areas where improvements are required:

  • Person-centred care, including supporting adults with finances and medication
  • Trauma-informed approaches
  • Multi-agency working and coordination
  • Mental capacity, particularly for adults who are self-neglecting
  • Safeguarding thresholds and referrals
  • Consideration of fire safety measures/risk assessment

Key documents:

Last updated: 28 February 2024