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SARs – National

Please find below SARs and/or Research that has recently been published:

King’s College, London

King’s College has recently produced a report looking at homelessness, rough sleeping and the learning from SARs. It can be found by following the link below;

Norfolk SAB

Mr G was an elderly man with dementia and a range of other health conditions. In June 2017 Mr G was admitted to an acute Norfolk hospital following an incident in a previous care home which led to him falling and sustaining an injury (not a fracture). While in hospital his behaviour became more challenging, leading to his detention under the Mental Health Act 1983. Mr G was admitted to a psychiatric hospital outside of Norfolk as there was not a bed available at the time in Norfolk.

Shortly after arriving at the psychiatric hospital Mr G was admitted to the local acute hospital with a suspected infection and dehydration. After treatment there was a rapid improvement in the behavioural elements of his presentation. Overall, despite it being an out of area placement, Mr G appears to have had a relatively positive experience of care. In mid-August 2017 Mr G was transferred back to a Norfolk psychiatric hospital and his experience of this hospital also appeared broadly positive. Hospital staff seemed to understand well Mr G’s care needs and demonstrated an ability to develop and implement an appropriate plan for managing his physical health and bIn the second week of November 2017 Mr G was discharged from the psychiatric hospital to the care home. This arrangement was made under the ‘Discharge to Assess’ (DTA) pathway. (The DTA process provides 28 days of funding to assess clients in a less restrictive environment). DTA does not apply to patients detained or admitted to any mental health hospital. Mr G’s bed was held open first for 7 days, which then increased to 14. This would have allowed him to return at any point if necessary. The care home, believing that Mr G was discharged under the DTA process, reported that they were not aware Mr G could return to the psychiatric hospital (although several occasions where such information was conveyed to the care home are noted).

The care home had significant difficulties in effectively managing Mr G and providing him with adequate care. Personal care was often refused by Mr G, or delivered under challenging conditions. The Dementia Intensive Support Team (DIST), who remained in contact with Mr G, noted concerns about the care home’s ability to safely manage Mr G but this was not flagged as a safeguarding referral. Despite their concerns, DIST proposed to discharge Mr G to the care of his GP, based on an apparent improvement in his presentation. The relationship between Mr G’s family and the care home broke down over the next 3 days regarding Mr G’s care. There was significant concern for Mr G’s physical health and a paramedic was called who arranged for Mr G to be admitted back to hospital.

The ambulance crew who admitted Mr G to hospital were so concerned about Mr G’s physical state that they made a safeguarding referral, querying the possibility that Mr G had experienced abuse and neglect. The care home has disputed the concerns documented by the ambulance service, stating that these concerns were simply those relayed by the family.

Mr G sadly died in hospital 3 days later on 22 November 2017.

Further information can be found on the Norfolk SAB website;


The National College of Policing UK has recently produced research in relation to SARs, the link can be found here;

Scroll to the bottom of the page and you will find the link to the SAR briefing – Safeguarding Adults Review – Fourth Briefing

Lancashire SAB – ‘May’

May was 70 years old, she was a White British woman and one of non-identical twin girls.  She also had two other sisters and a brother.  May is described as having some learning difficulties, though she worked until being made redundant at 50 years of age.

Following the death of her mother and then her father, she continued to live in the family home with support.  May had complex medical problems and died in July 2018 as a result of sepsis.


A learning brief has also been published.


Community Care headline in July 2019: Council breached Care Act in case of woman who died of scabies related complications, review finds.

This was a review into the death of Jo-Jo, a woman with Down’s Syndrome.  She had been known to Hackney Social Care since March 2007.  Jo-Jo needed support with personal care, diet, finances and maintaining relationships.  She had a history of severe eczema covering her whole body.


Alcohol and Safeguarding Adult Reviews

In 2019 Alcohol Change UK published a report into the prevalence of alcohol misuse issues within Safeguarding Adult Reviews, the link for the report can be found below.

London Borough of Newham – A thematic review of Safeguarding Adults Review (June 2019)

Newham SAB identified four vulnerable men who died between 2017 and 2018.  The men’s cases highlighted similar themes which increased their vulnerability.  These included their age, numerous hospital admissions, limited informal support in the community, concerns of self-neglect or neglect by another and limited engagement with statutory services.

Thematic SAR Final Newham

Learning Points;

  • Professionals need to be competent in communicating with the adult and partner agencies to conduct a holistic risk assessment which should support professional decisions.  All risk assessments should be recorded in a standardised format.
  • A hospital discharge planning policy and procedure should be embedded that clarifies communication pathways and accountability to support safe and effective discharge for vulnerable adults in the London Borough of Newham.
  • Partners need to understand the concept of ‘safeguarding is everyone’s business’ and the need to share information and work together to achieve the best outcomes for vulnerable adults.  Local Authority have the legal duty to conduct the safeguarding section 42 enquiry or make sure others do.
  • Professionals must demonstrate skill and competence in applying the Mental Capacity Act 2005 key principles and statutory duties throughout work with vulnerable adults.  This includes identifying when an individual makes an unwise decision versus the individual not having the ability to make a specific decision.  Professionals should seek legal advice regarding High Court Inherent Jurisdiction applications in cases where the Adult at Risk has capacity, all options to mitigate the risks have been exhausted, and a risk considered in vital or public interest remain.
  • The Local Authority offer Carers a Carers Assessment to support them in their role.  Care Act 2014.
  • Advocacy must be offered to an adult to support them in their assessment when they have substantial difficult to engage and there is no appropriate individual to support them though an assessment.  Care Act 2014.