Learning from Experience Database - Serious Case Reviews

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Mr Q Buckinghamshire

Adult Q

Buckinghamshire Safeguarding Adults Board commissioned an independent Safeguarding Adults Review (SAR) following the death of Mr Q who was aged 74, who had a long standing history of mental and physical health needs. At the time of his death he had just been discharged from a stay in hospital and was being supported at home by carers. The coroner recorded that he died from bronchopneumonia and associated severe kyphosis which was secondary to ankylosing spondylitis.

It is clear from this case that although there was clear evidence of good practice from the care agencies and his general practitioner, that there were issues regarding communication between agencies and the lack of identification of the vital role played by his informal carer.

Executive Summary Mr Q

Mr Q SAR Report