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SARs – Merseyside

Ms B

SAR on a page‘ is an overview of the learning from Ms B.  It is the first of a series of ‘SAR on a page‘ in relation to SARs and Learning Reviews undertaken by MSAB and its member agencies.



Below is the practice briefing that pulls together recommendations and actions for practitioners from a safeguarding adults review that was arranged by Liverpool Safeguarding Adults Board in relation to Ms B recently. 

This briefing should be shared with all relevant staff and  should be used to reflect on practice in order to continuously learn and develop and improve outcomes for service users.   If you have any queries or would like any clarification regarding this briefing please email: [email protected]

MSAB SAR Practice Briefing

Knowsley SAR- Grace

She was taken to the hospital just before 4pm by her mental health support worker employed by 5 Boroughs Partnership NHS Foundation Trust (5BP). Grace had telephoned her support worker as she was in a ‘low’ mood and told her she had taken an overdose of non prescribed drugs the previous day.

Grace left A&E before being medically assessed and returned to her home but then returned to A&E around 7pm the same day. It was thought that she had left again (Grace had done this on a number of previous A&E visits). The police were alerted and visited Grace’s home address, where Grace’s boyfriend’s mother said Grace had been home but left again.

She was found lifeless in the A&E department disability access toilet at 8.20pm that evening.

The Coroner’s Inquest in spring 2014 confirmed that Grace had taken her life by hanging. Toxicology reports indicated that she had, “a high concentration of THC in the blood together with carboxyl-TH and the results suggest recent cannabis and/or cannabis resin use” Grace was known to be a long term heavy user of ‘skunk’ a strong form of cannabis.

A Serious Incident Review Inquiry (SIRI) conducted by Whiston hospital shortly after Grace’s death concluded that, “Grace’s whole (adult) life revolved around the risk of suicide and this has been extensively documented particularly in the 5 Boroughs Partnership NHS Foundation Trust records. The evidence from Grace’s history strongly supports the view that by her late teens her self-harming behaviour was strongly entrenched, which put her at high risk of suicide”.

Please click on the link below for the full Safeguarding Adult Review:

Serious case review in the case ‘Grace’

Domestic Homicide Reviews (DHRs)

Sometimes there may be two reviews agreed for example a SAR and a DHR in these cases the reviews are joined with a single report being produced.

Domestic Homicide Reviews (DHRs) were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Victims Act (2004) which came into effect on 13 April 2011.

Under guidance issued by the Home Office, any incident of domestic violence or abuse which results in the death of the victim requires a DHR to be carried out by the local Community Safety Partnership.

The purpose of the multi-agency review is to ensure that agencies are responding appropriately to victims of domestic violence and to apply any lessons learned through an action plan or recommendations.

There are no inquiries into who is culpable, this is for the court or coroner to decide.

DHR 11: Review for the deaths of ‘Lynn’ and ‘Natalie’