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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.
Our sector learning briefing series has been produced to share learning from our reviews, including learning reviews and Safeguarding Adults Reviews.
Each sector learning briefing is aimed at a different area of the adult safeguarding sector and draws out particularly relevant learning from our published reviews. This is not to say that there isn’t wider learning to be taken from our reviews, but that the learning contained in these briefings is particularly pertinent to the sector. These sector learning briefings are intended to be a concise exploration of key themes identified in our reviews. They will be updated with any new identified learning or themes, as needed.
West Sussex Safeguarding Adults Board Response to Provider Learning Review (May 2025)
This review explores the system response and learning following an investigation into reports of organisational abuse and neglect across a large provider of residential and nursing care in West Sussex, during 2016 to 2019. The provider is no longer in operation and the report explores the changes that have occurred as a result of this learning and identifies priorities for further change locally, regionally and nationally for preventing and responding to organisational abuse.
The findings and learning from this review have been shared with and agreed by all Safeguarding Adult Board agencies and as a partnership we offer our sincere condolences to the families, carers, and friends of the adults involved.
The West Sussex Safeguarding Adults Board extends its thanks to everyone who contributed to this review, especially the relatives and staff who generously shared their time and experiences.
This report provides crucial insights into the learning from the investigation, guiding our ongoing work to build on the significant improvements already made.
We acknowledge the progress achieved across all services since these events, reducing the risk of recurrence, and will continue to monitor the improvement work taking place.
As the recommendations require, we will work both regionally and nationally to share our experience to influence change, improvement and support when working with the provider market.
Key documents:
At the time of publication of this report, Tom is 41 years of age and refuses to be defined by his disabilities. He has a diagnosis of cerebral palsy, complex postural needs, and has a sight impairment. Tom requires a carer to be available 24 hours a day and uses a motorised wheelchair at all times. Tom is currently living in his own accommodation in Chichester, after living in an emergency place of safety, a residential care service, since August 2020.
Prior to his move, Tom lived in the community with his now ex-wife and his live-in carer. From 2016, Tom began to experience neglect and emotional/psychological abuse by his then wife, and paid carer. The abuse and neglect became significantly worse over time, and Tom became isolated from his family and friends. In 2020, Tom’s friend became concerned about Tom’s circumstances, following contact from Tom. This led to Tom’s friend contacting Tom’s mother, who subsequently made a safeguarding referral to West Sussex County Council.
In October 2024 the West Sussex Safeguarding Adults Board published a Safeguarding Adults Review in respect of Tom. Following his involvement in his Safeguarding Adults Review, Tom attended our conference in October 2024. At the conference, Tom shared his experience of abuse and neglect at the hands of his then-wife and paid carer, as well as his experience of the safeguarding process.
A message from our Board Support Officer:
“I am pleased to share with you an article featuring Tom Somerset-How, which has been developed from an interview held at our Safeguarding Adults Board conference in October 2024. Tom shared his story with courage and clarity, and made a real impact on all of us. The opportunity to read Tom’s story in his own words, within this interview, is extremely powerful.
I’ve had the privilege of working with Tom as part of the Safeguarding Adults Review process, and I can honestly say his openness, transparency, and commitment to change have been admirable. To Tom, I’d like to say a huge thank you for your invaluable contribution to this process, and for always welcoming me with a cup of tea and a friendly smile! Your kindness and warmth throughout this journey has not gone unnoticed.”
Read the article:
This meta-analysis was commissioned by the West Sussex Safeguarding Adults Board. East Sussex Safeguarding Adults Board and the Brighton & Hove Safeguarding Adults Board contributed to the meta-analysis by providing Safeguarding Adult Reviews (SARs) for analysis, and by being part of the review panel.
This analysis includes the circumstances of two adults who were referred to the Board; IL and TB, who both had a history of self-neglect. At the point of referral for IL and TB it was agreed that, although individually both cases met the criteria for a SAR, there was a need for wider learning regarding self-neglect within Sussex as a whole. To do this, a thematic analysis of findings from recent SARs involving self-neglect was commissioned to consider changes to practice, process, policy, and procedure.
Key documents:
