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SARs – National

Please find below some SARs that have been completed recently:

Rochdale SAR – Tom

This case is about Tom who was found dead at Address One on a day in spring 2016. Tom was a kind and caring man who once held a responsible position working within the charitable sector. Unfortunately, Tom began to misuse alcohol and his lifestyle changed. He lost his career, his long-term relationship ended and he began living on his own at Address One.

Tom began to associate with a group of men and women who had a similar lifestyle to his own and alcohol was a common bond. These people frequented Address One, some with the permission of Tom but others were not welcome and abused Tom’s hospitality. There is evidence they stole personal possessions from him and money from his bank account.

Tom was well known to statutory and voluntary agencies. He was well liked by those professionals who dealt with him. However, Tom’s lifestyle and the lifestyle of others who frequented Address One attracted notoriety. Agencies suspected Tom was being exploited by these associates; a safeguarding alert was made and two multi-agency strategy meetings were held.

Although some actions were taken by agencies, Tom was found dead by Lynsey. Greater Manchester Police launched a homicide enquiry and arrested Male A, a man who had recently started to frequent Address One. He was charged with Tom’s murder and pleaded guilty when he appeared before a Crown Court in autumn 2016. Male A received a term of life imprisonment and must serve a minimum of 21 years in prison.

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

SAR Rochdale Tom

Worcester SAR- Lee Graham

Lee Graham was a white British young person with a diagnosis of severe learning disability, Down’s Syndrome and aspects of autistic spectrum disorder, e.g. some obsessional behaviours. He had communication difficulties, but by using a limited vocabulary and Makaton signing he was able to make his needs and choices known to the people who knew him well. Lee Graham was also diagnosed with epilepsy soon after birth, but had had no symptoms for several years. He was short-sighted and required glasses.

Lee Graham had close relationships with his family; his Mother, Father, Sister and Brother. Sadly Lee Graham’s Father died suddenly and unexpectedly in July 2011.

Lee Graham enjoyed sports; swing ball, basketball, football and swimming. He liked watching DVDs, particularly Only Fools and Horses, and listening to music, including The Black Eyed Peas.

Lee Graham’s experienced extreme anxiety and found change difficult. His behaviour could escalate quickly and become very challenging. Lee Graham could be reluctant to engage in physical activities, often being happier watching. If he did not want to do something it could be very difficult to persuade him otherwise. He had received long term treatment for his anxiety and stress with tranquillisers.

The Designated Nurse for Worcestershire and the Lead Reviewer visited the family in March and met with Lee Graham’s Mother, Sister and Brother. The purpose of the Case Review. They provided helpful background information regarding Lee Graham.

The family are concerned that obesity was a key factor in Lee Graham’s death and are keen to ascertain whether appropriate steps were taken to address his weight gain in the years before his death. Lee Graham’s Mother had raised her concerns with a number of professionals over the years, including the Consultant Psychiatrist, the Community Learning Disability Nurse and the Manager of the Residential Unit.

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

Worcestershire SAR Lee Graham

Buckingham SAR- Miss T

This young woman, referred to as Ms. T throughout this report to ensure anonymity, was of Asian origin. She was born in Buckinghamshire and, it is believed, lived in the County for most of her life. She studied accounting at Bradford University and lived with her parents until sometime in 2014. At the time of her death, and as far as can be established, Ms. T was living alone, in a social housing tenancy.

Ms. T had a history of asthma, type 2 diabetes and mental ill-health (paranoid schizophrenia). She had been known to the local mental health services for several years and had also been supported by primary care. She was aged 34 at the time she was found deceased. It would appear from agency records that she was last seen in November 2015 but was found in an advanced state of decomposition some 3 months later. The cause of death could not be established.

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

Bucks Miss T SAR

Buckingham SAR- Miss T

Adult Q was 74-year-old man who lived alone in a private rented dwelling. People who knew him painted a picture of a man who had lived a varied and exciting life, travelling the county, on the road – driving a lorry, or riding a traditional horse-drawn caravan, or on the canal network, travelling and living on a barge. During his life Adult Q had been married, and had a son. Adult Q lost contact with his wife and son after they moved away. Adult Q’s son was three years old at the time. Adult Q also had a sister who he used to regularly visit when she was in a nursing home until her death.

Adult Q settled in Buckinghamshire and became a part of the local village community. Adult Q had one particularly close friend, Ms Y, who he used to see very regularly, they went on trips, and he became part of Ms Y’s family – he was like a second father to her. Over time Ms Y began to provide Adult Q with a significant level of support, helping him to look after himself, and his home.

Adult Q had a diagnosis of Bipolar Affective Disorder and Ankylosing Spondylitis1 – a long term inflammatory condition affecting the joints of the spine, and later a diagnosis of Parkinson’s disease. Adult Q had close friends locally who he saw throughout the week, and who provided him care and support. Adult Q has also been described as an active member of his local church, attending the mobility group, a social café, and weekly church

Adult Q died on 6th April 2016. The cause of his death was noted by the coroner to be bronchopneumonia2, with associated severe kyphosis3 which was secondary to that ankylosing spondylitis. At the time of his death a number of agencies were involved with Adult Q in the context of his health and needs for care and support. Agencies also became involved in a crisis period, responding to an allegation of financial abuse, and concerns raised through his care provider and informal support networks, regarding his mental state, home environment, and behaviours of self-neglect.