Published safeguarding adult reviews (SARs)
SAR Jack - published September 2024
Jack was 27 years old when he took his own life in July 2022.
Jack experienced a lot of trauma in his life, including the loss of loved ones. He was vulnerable to abuse and often struggled with challenging behaviour. He didn't have a stable home and spent a lot of time on the streets.
Due to these challenges, Jack had to deal with many different organisations and services. These started before he was born and continued until his death. He was often in and out of prisons, homeless shelters and hospitals.
The review showed that people who worked with Jack understood his problems with alcohol, homelessness, and getting into trouble with the law. They recognised that his past experiences had a big impact on him and made him vulnerable.
Because of this, the review focussed on what is working well and what could be strengthened.
Read the report
SAR Jack report [208.5 KB] [docx]
SAR Gwen and Ian - published January 2024
In 2021, Gwen died soon after her admission to hospital aged 95.
Ian went into hospital in 2022 after rapid decline in his mental and physical health. He died the following month.
The circumstances of the deaths of Gwen and Ian were similar, so we reviewed them together. Both were living at home in a state of neglect, with family who had challenges with their caring roles.
There were difficulties with engagement and limited agency involvement. Chances to respond to needs and risks in a complete and coordinated way were missed.
Read the report
SAR Gwen and Ian report [389.5 KB] [pdf]
SAB response to SAR Gwen and Ian [59.6 KB] [docx]
SAR Finley - published January 2024
Finley was in his early 30s when he died in 2021 from drug toxicity.
Aged 16, he was diagnosed with schizophrenia and spent nearly two years in an adolescent unit. He was then placed in supported housing. Eventually the home could not offer the level of support he needed. He moved to private accommodation.
Finley was not always able to accept the support offered by services. He misused drugs and this was a high risk to his safety.
The review highlighted several issues and learning:
- Engagement with families when someone has fluctuating capacity.
- Responding to indicators of cuckooing.
- Dual diagnosis.
- Multi-agency response to self-neglect.
Read the report
SAR Finley report [459.7 KB] [pdf]
SAB response to SAR Finley [147.5 KB] [pdf]
SAR Donna - published December 2023
In July 2021, Donna died suddenly shortly before her 43rd birthday. She was alcohol dependent. The cause was ‘sudden unexplained death in alcohol misuse’.
Key findings from the review were that:
- agencies working with Donna did not co-ordinate their response to her needs and risks
- opportunities to make safeguarding enquiries were missed
- her life experiences were not explored
The review also showed the impact of alcohol use and self-neglect on Donna’s life.
Read the report
SAR Donna executive summary [315.3 KB] [pdf]
SAB response to SAR Donna [156.2 KB] [pdf]
SAR Donna family statement [14.9 KB] [docx]
SAR Hannah - published December 2023
In May 2022, Hannah died from a head injury. Hannah was dependant on alcohol at the time and it caused significant physical harm. She had been to the hospital many times and was taking a lot of different medications.
The review explored:
- how she neglected herself and the harm caused by alcohol
- multi-agency approaches to managing risk
- considering carers
- understanding the person
The review also looked at:
- how different organisations work together on complex cases
- who we mean when we talk about a 'multi-agency' team
- how we coordinate, especially when the local authority is not involved.
Read the report
SAR Hannah report [701.9 KB] [pdf]
SAB response to SAR Hannah [61.7 KB] [docx]
SAR Charlie - published May 2023
Charlie had a short and complex life. He had suicidal thoughts when he was a teenager. He often self-harmed and refused hospital treatment. Charlie came out as transgender, identifying as male, but his family continued to refer to him as female.
He was in hospital twice under Section 2 of the Mental Health Act. This was due to his repeated self-harm. Charlie then moved into temporary accommodation in Brighton. He continued to self-harm and abused alcohol. Shortly after he moved in, it is believed that Charlie took his own life aged 18.
To understand why Charlie died, the review focused on services, systems, commissioning and assurance.
Read the report
SAR Charlie executive summary [68.1 KB] [docx]
SAB response to SAR Charlie [60.3 KB] [docx]
Thematic review: Working with multiple complex needs and trauma – published November 2022
This Thematic Review examines the deaths of four women who:
- lived in East Sussex
- were aged between 19 and 51 years old
- experienced trauma, violence and loss in their adult lives
- died from suicide or from causes linked to drug overdoses
- died between May and November 2020
The women did not know each other but had contact with some of the same health and social care services.
The review focused on how well services identify and respond to women with:
- multiple complex needs
- a history of trauma
- difficulties engaging with support
It considered whether services have the knowledge, skills and experience to effectively support people with these needs.
Read the report
Thematic review report [176.6 KB] [docx]
SAB response to Thematic review [199.2 KB] [pdf]
SAR Ben - published September 2022
Ben was a 60-year-old man who had lived in a care home in Eastbourne for over 30 years. He had learning disabilities, autism, paranoid schizophrenia and Type 1 diabetes.
He went into hospital with bad foot ulcers. His condition was so severe that amputation was not an option. They transferred him to a hospice where he died.
The review examined the strengths and weaknesses in how agencies worked together to safeguard Ben.
The board drew on learning from SAR Adult A published in October 2017 which had similarities with Ben’s circumstances.
Read the report
SAR Ben report [440.1 KB] [pdf]
SAB response to SAR Ben [150.3 KB] [pdf]
SAR Anna - published May 2022
Anna died in hospital of natural causes aged 85. On admission to hospital, she had multiple bruises and skin tears on her body.
There were historical concerns regarding abuse of Anna by her daughter. She was placed in residential care for a year. Five months before her death, Anna returned to live with her daughter.
This review focusses on how agencies worked together to:
- evaluate and understand coercion and control
- protect potential victims of domestic abuse
Anna’s death shares similarities with SAR Adult B (February 2020). Anna’s review explores whether previous learning has been put into practice.
Read the report
SAR Anna report [142.8 KB] [docx]
SAB response to SAR Anna [204.3 KB] [pdf]
Adult C SAR - published December 2020
Adult C experienced severe domestic violence and coercive control from her partner. This review focuses on the last 12 months of her life.
She had multiple complex needs. These resulted from drug and alcohol dependency, mental health (including self-harm) and homelessness. She died in 2017 from mixed drug toxicity.
The review showed:
- difficulties finding accommodation for women with complex needs.
- gaps in information sharing about domestic abuse between agencies
- services are not tailored to women with these multiple complex needs
Read the report
Adult C SAR - learning briefing
SAB response with a statement from Adult C’s family [78.5 KB] [docx]
Adult B SAR – published February 2020
Adult B died in hospital of natural causes aged 94 in 2017. When admitted, she had 26 unexplained injuries. These included a fractured nose and jaw, as well as old and new bruising to her face, arms and legs. The hospital diagnosed her with sepsis and pneumonia, and she died eight days later.
This review evaluated multi-agency responses and the support provided.
This case showed that:
- professionals did not progress to a safeguarding enquiry because Adult B had capacity and did not consent
- systems do not always allow staff to understand the full historical and current context
- a lack of curiosity and confidence to challenge family members puts vulnerable people at risk
Read the report
Adult B SAR report [360.0 KB] [doc]
Adult A SAR – published October 2017
Adult A was living in a nursing home in East Sussex, commissioned by NHS West Kent Clinical Commissioning Group.
He died due to sepsis, infection of his legs, diabetes and cirrhosis. Subject to a Deprivation of Liberty, he lacked capacity to decide where to live. There were concerns of self-neglect as he often refused care and treatment.
The review shows how crucial it is for all agencies to work together. We must share expertise to plan and deliver services to meet people’s care and support needs.
Read the report
Adult A SAR report [114.4 KB] [docx]
