Worcestershire Published Safeguarding Adults Reviews

A Safeguarding Adults Review (SAR) is a multi-agency review process which seeks to determine what relevant agencies and individuals involved could have done differently that could have prevented harm or a death from taking place.  The purpose of a SAR is not to apportion blame.  It is to promote effective learning and improvement to prevent future deaths or serious harm occurring again.

John  (January 2024)

Themes – Self-Neglect, Making Safeguarding Personal (MSP), Multi Agency Working (Managing Risk/Information Sharing)


John was a 54 year old white male who had a history of alcohol, substance misuse, and suspected suicidal incidents following the loss of his family network.  He had previously slept rough, but not at the time of his death.

Learning from this review included:

    • Self-Neglect is complex and requires a Multi-agency approach  – Self-Neglect Policy & CARM Framework
    • Making Safeguarding Personal (MSP) – Exploring methods of preferred contact
    • Managing Risk – Multi-agency approach

Joseph  (December 2023)

Themes – Making Safeguarding Personal (MSP), Care Homes, Discharge to Assess, Recordings (MDT),  Mental Capacity Act (MCA)


Joseph was a 79 year old male who had multiple health conditions which left him extremely frail as he advanced in years.  Falls and fluctuating metal capacity increased.  Joseph moved to a residential care home where he had a further fall which resulted in hospitalisation, he died the next day from aspiration pneumonia.

Learning from this review included:

    • MSP understanding the person – Health Passports
    • Assurance of quality of care in residential care homes
    • Discharge to assess and other placements/funding for care
    • Quality of recording and reviewing Multi-Disciplinary Team (MDT) meetings
    • Mental capacity and cognitive impairment

Adult M (December 2023)

Themes – Making Safeguarding Personal (MSP), Multi-agency working, Mental Capacity Act (MCA), Hoarding


Adult M is a 83 year old white British female, who has limited mobility, cared for by her son for 20+ years.  Son has suspected care and support needs not established.

Learning from this review included:

    • MSP and Multi-agency working
    • Appropriate use of Mental Capacity Act/Assessment
    • Appropriate use of policy/guidance for Hoarding

Good practice from this review included:

  • The S42 enquiry has worked successfully to enable the social worker to build a relationship with Adult N that has led Adult N to accept more help and support for his caring role.
  • The GP knew the family well and were able to add light to the relationships and care that Adult N had successfully delivered for over 20 years.
  • The community nurses recognised and discussed concerns as they arose.
  • Arrangements were made by the GP practice for Adult M to continue to receive care when Adult N had refused access to nurses at home.

Dee (November 2023)

Themes – Alcohol and substance misuse,  Homelessness,  Discharge Pathways


Dee was a 48 year old white female, who had previously been homeless in another area of the country due to alcohol misuse.

Learning from this review included:

    • Pending homelessness – trigger for substance misuse – proactive approach CARM framework? 
    • Appropriate agency notification for temporary moves?
    • MDT meetings for discharge planning regarding homelessness
    • Time consideration for homelessness signposting

Good practice from this review included:

  • Good support from agencies, in particular Homeless and Rough Sleeping Nursing Team (not home area)
  •  Empathetic support from GP (not home area)
  • Worcestershire agencies worked hard together to find and offer accommodation

Peter (November 2023)

Themes – Professional curiosity,  Self-harm, substance misuse,  Cuckooing/Home invasion, Exploitation,  Multi-agency working,  Self-Neglect


Peter was a 66 year old white male, who had mobility issues and a history of substance misuse, he associated with other persons who did the same.  It was established that his home was being used to deal drugs by known Birmingham nominals.  Peter had been victim of physical abuse and financial exploitation, he had also attempted suicide.  Peter’s ‘friend’ Mark had assumed a caring role which was not fully understood.

Learning from this review included:

    • Self-harm injuries and safeguarding concern correlation
    • Non assumption of the ‘Carer’ role
    • Importance of Carers assessments
    • Applying Self-Neglect policy

Good practice from this review included:

Ruth (July 2023)

Themes – Multi-agency working, Making safeguarding personal, Professional curiosity,  Neglect and Self-neglect


Ruth was a 49 year old, white female, who had a range of physical and mental health challenges.  Ruth was subjected to sexual, physical, and financial abuse by a ‘friend’.  The abuse was arguably ‘hidden in plain sight’.  Whilst Ruth had capacity, an assumption was made that she had given consent for Simon (‘friend’) to adopt the role of her ‘carer’.

Learning from this review included:

Dorothy (March 2023)

Themes – Assessments, Care Homes, Resident on Resident incidents, Dementia, Listening to Carers


This SAR identified learning in a residential care home where Dorothy sadly died after an incident involving another resident.

Learning from this review included:

  • Actions which should be considered when making an assessment for a placement
  • Things Residential Homes should consider when managing resident on resident incidents
  • The importance of listening and understanding the situation from the perspective of the carer

Alison (January 2023)

Themes – Self-Neglect, Managing Complex Cases, Multi-agency communication, Mental Health, Alcohol Abuse, executive function


Alison was a 55-year-old woman who lived alone in home she owned, which had fallen into significant decline over a long period of time. Alison had a history of mental ill health and alcohol abuse.

The learning from Review

Practitioners needed to ensure they understood and apply:

Lucy (November 2022)

Themes: Transition, Mental Capacity Act, Best Interest Assessments, Professional Curiosity, Carer Support


Lucy was a 19-year-old woman who had complex needs from birth which required 24 hour care.  She tragically died at home following an accident.

Learning from this review included:

  • The importance of starting transition planning for young people starts as early as possible
  • Ensuring that the Mental Capacity Act is applied when young people are moving from children to adult services.
  • professionals to satisfy themselves that family carers have the capacity and the support necessary for them to provide safe care to adults with complex needs within the family home.

BS (July 2022)

Themes: Professional Curiosity, Self-Neglect, Multi-agency work, Balancing Consent with Risk


BS was a lady who had very little involvement with statutory services throughout her life. She was sadly found deceased at her home, having likely died a few weeks earlier.  During her earlier life there were no reasons to be concerned about BS’s welfare however as she aged, she became more isolated, and her self-care deteriorated, and the house became chaotic and unsafe. Although her son tried to support her, she made it clear she wanted no interference and threatened to stop seeing him if he informed anyone.

Learning from the review included:

  • Policies are in place to guide practice regarding self-neglect and hoarding but are not always referred to. Link to Self-Neglect and Hoarding Policy
  • Listening to concerns that are raised by families and members of the public.
  • Information sharing and developing more holistic picture. Link to CARM framework
  • Consent and consideration of use of cumulative risk from ongoing concerns
  • Environmental health teams can be a source of support and help where there are issues of self-neglect that may cause a public health issue

Joan, Kate & Laura (September 2021)

Themes: Neglect, Transition, Mental Capacity, Best Interest Assessments, Advocacy, Carer Support.


Jane Kate and Laura were a mother and two daughters who lived together in local authority housing.  Over an extended period, whilst Kate and Laura were both children, agencies were concerned regarding severe neglect. This neglect presented in the form of physical, educational, medical, and emotional neglect. Joan, the mother suffered from depression and there was cause for concern regarding her mental health, her mental capacity, and her ability to effectively care for the girls. Kate has a learning disability and diagnosed with autism. Laura was diagnosed with epilepsy and had to take on a significant caring role within the family as both a child and young adult.

Learning from this review included:

  • Ensuring that issues of neglect and the reasons behind them are continually understood, assessed and  addressed , including when people transition from children’s to adult services
  • The use of advocates is used where there is a question around individuals’ mental capacity
  • Ensure that Carers are assessed to make sure they have the right support to ensure they can care effectively.

Mr & Mrs Jones (September 2021)

Themes:  Self-Neglect, Multi-Agency work, Advocacy, Mental Capacity Act, Professional Curiosity


Mr and Mrs Jones were an elderly couple who had no next of kin and became ill through chronic self-neglect. They were unknown to agencies apart from their GP and had been proudly self-sufficient and independent.  Deteriorating physical and mental health adversely affected their ability to care for themselves and each other, material standards in the home also declined which contributed towards their ill health. They declined help and as far as possible, avoided the services which were offered to them.  The couple became known to agencies following the hospitalisation of Mrs Jones following a fall.

Learning from this review included:

  • Ensuring that the Mental Capacity Act is embedded in practice and applied appropriately
  • Utilising services of Mental Capacity Advocates
  • A review is undertaken of the Self-Neglect Policy (completed) Link to Self-Neglect and Hoarding Policy
  • Use of professional curiosity in self-neglect cases, looking at information wider than agencies (e.g. Neighbours)
  • Use of Multi-agency meetings in complex situations Link to CARM framework

Mary (March 2021)

Themes: Think the Unthinkable, Professional Challenge, Multi Agency Working, Best Interest Decisions


Mary, a young lady in her early 20’s, was found to be approximately 30 weeks pregnant. The perpetrator was her step-farther and Mary would not have had mental capacity to consent to a sexual relationship. Mary received a personal health budget (PHB) managed by her mother. She had support from Personal Assistants (PA), attended Day Services, and spent time in replacement care at a specialist replacement care centre.

Learning from this review included:

  • Best interests’ decisions are more robust when several of those that care for and know a person well are included, providing the decision is not an urgent one
  • Early collaboration regarding presentations of a person without capacity for specific decisions to provide a history, may lead to a prompter diagnosis
  • Thinking the unthinkable alongside other possibilities and the use of professional challenge may present earlier opportunities to protect
  • Where a person is in receipt of fully funded continuing healthcare (CHC) clarity of the governance, coordination, key worker, and day to day oversight provides safeguards and assurances regarding how a national framework is being delivered locally
  • Safeguarding decision making is more robust when information is gathered from a range of professionals involved in the care of a person with care and support needs
  • The role of Personal Assistants when directly employed by a family needs clarity so that vital information is not missed

Thematic SAR Regarding People Who Sleep Rough (October 2020)

Themes: Rough Sleeping, Self-Neglect, Mental Capacity, Multi-agency work, housing legislation

This Thematic Safeguarding Adults Review looked at the circumstances of five people who slept rough across the county.  Four of the people identified were deceased. Of these, one died in hospital, one died whilst sleeping rough and two ended their own lives. One of the five was alive and although he had been sleeping rough, he had acquired a settled address by the time of this SAR.

Learning from this review included:

  • The need to improve multi-agency working (following the review the WSAB introduced a Complex Adult Risk Management (CARM) framework Link to CARM framework
  • The need to consider the impact of physical or mental impairment or illness, including substance dependency and dual diagnosis on the risks experienced by adults who are rough sleepers and the service response to those issues
  • Ensuing that the requirements of the Care Act and Mental Capacity Act, alongside housing legislation is understood across all practitioners who work with the homeless and rough sleepers
  • The Self-neglect policy considers the specific needs for people who are homeless or sleep rough. (This was addressed in the review of the policy) Link to Self-Neglect and Hoarding Policy

Further information on Homelessness and Rough Sleeping, including information on work undertaken following this review can be found on our Homelessness and Rough Sleeping website page.

WSAB Homelessness and Rough Sleeping Page

Jane (June 2020)

Themes:  Making Safeguarding Personal and Person Cantered Care, Mental Capacity Act, Carers Support


Jane was 47 years old when she died in hospital in June 2018. The causes of her death were heart disease linked to high blood pressure, infected leg ulcers with septicemia and liver disease. Within the previous fifteen months, she had had five admissions to hospital related to these ongoing physical health concerns. For most of her adult life, Jane had also lived with mental health needs arising from a diagnosis of schizophrenia. She had long-term support provided through the Mental Health service. Although she had lived independently for many years, she had shared a home with her mother, Theresa, from her early twenties.

Learning from this review  included:

  • Person cantered care should include understanding the balance between what the individual wants and what the carer thinks they need.
  • Practitioners should understand their statutory roles and responsibilities for care provision made under Section 117, Mental Health Act 1983 and Care Act 2014
  • Parity of esteem between mental and physical health should be promoted
  • When addressing health and care needs with isolated people consider whether any of these could be met though a more sociable service

Historic Reports

Reports more than 3 years old are removed from the WSAB website but can be requested from the WSAB Business Unit by emailing safeguardingadultsbo@worcestershire.gov.uk

  • RN SAR (2019)
  • Neil SAR (2019)
  • Alan SAR (2019)
  • David SAR (2019)
  • Combined Domestic Homicide Review (DHR) and SAR Karen (2019)