The Board is required to commission Safeguarding Adults Reviews (SARs) for any cases meeting the criteria for these.  The Care Act 2014 introduced SARs, which were previously known as Serious Case Reviews.

Listed below are reviews commissioned and published by the Safeguarding Adults Board.

It is not currently a statutory requirement to publish reports; however it is recognised good practice to demonstrate the level of transparency and accountability needed to enable lessons to be learned as widely and thoroughly as possible. It is therefore our policy that all reports are published in full unless:

  • publication could be deemed to be detrimental to the person’s wellbeing or
  • the person, or their family member(s) who act/acted in the persons best interests, ask for the report not to be published

Where a report is not published for these reasons we will produce a practice briefing containing learning identified to ensure professionals are able to understand what happened and, crucially, what needs to change in order to reduce the risk of similar tragic events happening in the future.

A Safeguarding Adults Review was commissioned in to the long-term deterioration of Luke (pseudonym), a resident in a Somerset care home. Luke, aged 67 at the time of his death, had been a resident in the care home for about 18 months, and had had a long history of neglecting his own health and well-being before he moved there.  Luke had experienced a number of traumatic events in his life and, although Luke died from a diabetic foot ulcer, the focus of the report surrounds how agencies worked together in their approach to Luke and concerns about his mental capacity and neglect of his own wellbeing.

In this case a Safeguarding Adults Review (SAR) was not commissioned as it was determined that Kevin’s case did not meet the criteria for a SAR. However, it was agreed to instead undertake a review of Kevin’s case to determine what, if anything, the relevant agencies and individuals involved in the case might have done differently. This was so that lessons could be learned from the case, and those lessons applied to future cases with the objective of avoiding similar circumstances reoccurring. These lessons are summarised in the Practice Briefing.

Kevin was middle aged when he attempted to take his own life, shortly after the death of his partner, which had a life changing impact on his health. Kevin had a history of very high-intensity contact with his GP surgery, with often multiple contacts per day, and the Emergency Department at his nearest hospital.

Alongside this Practice Briefing new guidance, entitled “What to do if it’s not Safeguarding“, has been developed for professionals and organisations on initiating multi-disciplinary discussions where someone does not require a Safeguarding intervention.

A Safeguarding Adults Review was commissioned by the SSAB following a whole service safeguarding enquiry into allegations of the mistreatment of residents living at Mendip House, a care home for adults with autism near Highbridge run by the National Autistic Society.  None of the people living at Mendip House were Somerset residents; however, the review findings and recommendations include important learning for the commissioning and monitoring of out-of-area placements.

This thematic review, undertaken by Professor Michael Preston-Shoot, forms part of the strategic priorities for 2017/18 set by South West regional adult safeguarding leads and South West ADASS. The thematic review undertook an analysis of the nature and content of 26 serious case reviews commissioned by Safeguarding Adults Boards in the South West region from 1st January 2013 up to the implementation of the Care Act 2014, and 11 safeguarding adult reviews commissioned and completed by Safeguarding Adults Boards in the South West region since implementation of the Care Act 2014 on 1st April 2015, up to 31st July 2017.

Damien had diagnoses of Asperger’s Syndrome and ADHD.  He had a mild learning disability and misused a variety of substances, causing him to come into frequent contact with the police and mental health services.  His vulnerability was exploited by others who stole from him and misused his home for their own purposes.  Meeting the dual requirements of protecting both the public and Damien from harm, at the same time as treating him as capacitous and allowing him to live his own life with only the necessary oversight and control, tested services in Somerset.  In the last fifteen months of his life he was detained under Section 2 of the Mental Health Act on three occasions.  He was also made subject to MAPPA arrangements.  Damien died in hospital in July 2015 following an incident of self-strangulation in the residential unit that had been his home for two weeks following discharge.  A Practice Briefing Sheet has been produced by the SSAB with support from Damien’s family, outlining the key considerations for practice that arise from the review.

A Serious Case Review was commissioned by the Somerset Safeguarding Adults Board (SSAB) following the death of ‘Tom’ who took his own life in 2014, aged 43. Tom had sustained a traumatic brain injury in a road traffic accident in his early twenties, which left him with physical, cognitive and psychological issues. In addition, Tom had a dependency on drugs and alcohol. The independent report published by the board today concludes that despite numerous contacts with many health and care professionals and the concerns of family members he was not provided with appropriate support.

A Practice Briefing Sheet was produced by the SSAB together with the author of the review in June 2016, outlining the key themes and findings to emerge from the review.  

Case Debrief – Mr J (April 2016) 

In April 2016, a multi-agency case debrief was convened to extract lessons learnt following the death of an elderly, terminally-ill gentleman, Mr J.  It highlighted issues around the effectiveness of safeguarding and hospital discharge procedures, challenges of working with resistant families/individuals, and dealing with issues of self-neglect.  Although a Safeguarding Adults Review was not commissioned, the Board publishes below, in the interests of shared learning, a Practice Briefing Sheet which extracts the key themes.

In February 2016, the Board received the Serious Case Review of young woman with learning disabilities thought to have been the victim of domestic violence and sexual exploitation.  A Practitioner Briefing Sheet has been produced by the SSAB’s Learning & Improvement Subgroup, outlining the key themes and findings to emerge from the review.

In 2013 the Somerset Safeguarding Children Board and Somerset Safeguarding Adults Board commissioned research to explore the circumstances surrounding the lives of 13 young people who all had been, at some point in their lives, in care in Somerset but sadly died prematurely.  The research aimed to learn more about how services can best support care leavers in their transition to independent adulthood in order to better shape the future organisation and delivery of services to this vulnerable group.  Monitoring and improving transitions between and across services remain a priority for the SSAB.

This is the report of a Serious Case Review of the events at Parkfields Care Home that resulted in the conviction in April 2010 of the home’s registered manager for misappropriation of drugs, manslaughter and perverting the course of justice. Staff members had raised concerns in January 2007 that led to an extensive police investigation, which covered the care of ten older people then resident or formerly resident at the home, and Mrs Baker’s own medical care. The purpose of the Serious Case Review was to find out whether there were lessons to be learned about the way that professionals and agencies work together to safeguard adults in the period up to January 2007.

Hampshire’s Safeguarding Adults Board has kindly agreed to the SSAB referencing its fantastic ‘Learning from Experience Database’ on our own website.  The database contains links to national and local case reviews and aims to support the dissemination of learning, and in doing so promote evidence-based practice.  The database allows visitors to filter case reviews by theme (such as mental health or self-neglect), year and local authority area.