This serious case review was initiated following the death of Mr and Mrs R. The coroner has determined that both died of natural causes. Both had serious on-going poor health and both had been referred and were receiving support for health and social agencies. The coroner was satisfied in both cases that an inquest was not needed. This case falls outside the usual range of situations that would normally prompt a serious case review. Nevertheless, the case prompted much media attention, with speculation that the agencies could have acted differently, and the implication that they could have prevented both deaths. The SCR confirmed that there was no evidence of an abusive situation and the circumstances did not meet the criteria to be consideredas one of ‘safeguarding vulnerable adults’. However, The couple’s vulnerability increased as their health deteriorated and there were some points in the situation where that increasing vulnerability might have been more clearly identified. This may, in turn, have led to more robust efforts on the part of the agencies to persuade Mr and Mrs R to accept interim or longer term support. However, this did not emerge as a situation that would have met the criteria for intervention at the level of ‘safeguarding vulnerable adults’.