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Learning from Experience Database - Reviews from other Local Authority Areas

View Serious Case Reviews by Theme, Local Authority Area or Year

Tyrone Goodyear – Lewisham

Tyrone was a 24 year old man who committed suicide in February 2019.

The review examines the circumstances and issues leading up to Tyrone’s death, including homelessness (amid the ‘housing crisis’), mental ill-health and suicide prevention, all linked to Autism Spectrum Condition and learning difficulties.

We would strongly encourage all professionals to read the attached 7 Minute Briefing and the full report for this important review which can be accessed here:

LSAB 7 Minute Briefing – Tyrone Goodyear

Full Report

Mr C (Hampshire)

Hampshire Safeguarding Adults Board

Learning Summary following the Mr C SAR and the Thematic Review of Learning from SARs related to Learning Disability and Physical Health Care



The Hampshire Safeguarding Adults Board undertook a Safeguarding Adult Review regarding Mr C. Mr C had complex care and support needs and was being supported by a number of agencies. Mr C experienced a series of placement moves which had an impact on his emotional wellbeing resulting in a deterioration of behaviour. He stopped eating and drinking which led to a decline in his physical health. Concerns were expressed by Mr C’s care team that there may be an underlying physical cause for him not eating and drinking and losing weight. He was admitted to the local acute hospital trust for observations and diagnostic tests. Mr C was discharged 7 weeks later as it was felt that his condition was due to behavioural and not physical causes. Mr C was discharged to a nursing home in a poor physical state where he received end of life care and he died four days later.

Following Mr C’s death, concerns were raised about his care whilst in hospital, specifically that during his admission, he had not received the necessary tests to rule out a physical health condition as a root cause of his physical presentation. There were also concerns that he was transferred to a nursing home apparently at the end of life when this was not known to those that were receiving him into their care or the community learning disability team.

In addition to the Mr C SAR, the Hampshire Safeguarding Adults Board simultaneously commissioned a thematic review to examine this case alongside two previous SARs carried out under similar circumstances – Mr A (June 2013) and Ms B (Dec 2015). In all three cases, the adults had a learning disability and there were concerns about how their deteriorating physical health was managed. In each case, the death had been premature and unexpected. This raised questions about the effectiveness and embedding of the learning from the previous two SARs and so HSAB undertook a thematic review to identify progress in implementing learning from the previous cases. The Thematic Review also provided an opportunity to explore the blocks and barriers to embedding of learning and solutions to these.


Common issues identified across all three cases include:

  •  Understanding and application of the Mental Capacity Act.
  •  Access to advocacy.
  •  Effective management of transitions in placements and transfer to acute hospital care.
  •  Involving family in treatment decisions.
  •  Availability and access to the Learning Disability Liaison Nursing Service.
  •  Effective hospital discharge planning.
  •  Use of the Hospital passport.
  •  Continued use of the Care Programme Approach during hospital admission.


The learning from both the Mr C SAR and the Thematic Review is outlined below. HSAB has produced a multi-agency action plan designed to drive the improvements identified in the review recommendations:


1.  Understanding and application of the Mental Capacity Act 2005 (MCA)

All local agencies to:

  •  Adopt the national MCA Competency Framework and to review organisational training plans and provision against this.
  •  Adopt the refreshed Hampshire MCA toolkit as one tool for use across Hampshire.
  •  Introduction of agency executive MCA leads.
  •  Introduction of MCA champions in all service delivery areas.
  •  Ensure managers use supervision to support and assess competency and confidence of staff in application of MCA.
  •  Ensure staff can access guidance on eligibility and entitlement to advocacy support.
  •  Develop and support a culture of professional curiosity which enables professionals to explore and understand what is happening within an environment rather than making assumptions or accepting things at face value.


2. Communication and coordination

Health partners to:

  •  Agree a joint protocol for continuance of CPA when a person with a Learning Disability is admitted to hospital.
  •  Use the multi-agency Risk Management Framework to improve coordination and communication where patients who are admitted to hospital are not subject to CPA.
  •  Map current provision regarding the learning disability liaison nursing service.
  •  Introduce Learning Disability champions within hospital wards and departments.


3. Hospital passport

Health partners to:

  •  Review and develop the hospital passport to address the issues highlighted in the reviews and to include a persons wishes on who they want involved in their care, treatment, environment and discharge.


4. Discharge Planning

Health partners to:

  •  Review hospital discharges processes and revise to reflect learning from the reviews.
  •  Ensure care providers are advised of any change in clinical condition that occurs between the initial assessment and actual discharge date.


5. Transition

Local partners, led by Adults Health and Care to:

  •  Produce guidance on transitions/placement moves that sets out responsibilities of commissioners and providers as well as key agencies.


6. Escalation and challenge

  •  Professionals should feel able to challenge care and treatment decisions when it is felt these are not in the best interests of the service user and where necessary, escalate concerns to senior managers for resolution. HSAB has developed a multi-agency protocol to support this practice.


HSAB - Report of the Workforce Subgroup HSAB Mr C SAR

HSAB - Report of the Workforce Subgroup HSAB Thematic Review

Miss T – Buckinghamshire

Miss T

Buckinghamshire Safeguarding Adults Board commissioned an Independent Safeguarding Adults Review (SAR) following the death of Miss T, who was aged 34, living alone in Buckinghamshire.  It would appear from agency records that she was last seen in the November 2015 and found dead in an advanced state of decomposition some three months later. The case of death could not be established.  

It is clear from this case that although there was clear evidence of good practice from certain agencies, such as Thames Valley Police and her general practitioner there were also areas where practitioners could have communicated more effectively. It also highlighted the difficulty of respecting an individual’s right to a private life at the same time as trying to keep them safe from harm, in this case self-neglect.  

Executive Summary Miss T

Miss T SAR Report

Mr Q Buckinghamshire

Mr 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


X – Brighton & Hove

The Brighton & Hove Safeguarding Adults Board commissioned a Safeguarding Adults Review (SAR), following the death of ‘X’ who was aged 59 years and rough sleeping in the city. The Coroner recorded a verdict of ‘misadventure to which self-neglect contributed’.

There are two important recommendations to share with the network:

  1. Where it is known that an individual subject to a VAAR or any equivalent from another authority is resident in the area the receiving  LA should seek information about the alert from that authority and undertake their own multi- agency risk assessment to determine what action is needed by them.
  2. When reaching a determination about access to services the LA should ensure that all efforts are made at the earliest stage to establish a full antecedent history to include housing and medical records.

The full report and briefing for staff can be read here:
X Safeguarding Adult Review April 2017
Staff Briefing X SAR


Ms F – Wokingham

Ms F was a young woman who died of sepsis. With the exception of her GP, her case was not open to any service until just before her death, when she was referred to Adult Social Care by the Police. Other members of the household were well known to many services in Reading including Antisocial Behaviour and the Police, both as victims and perpetrators.

Details here:

icn_pdf Ms F SAR Executive Summary

Mr I – Wokingham

Mr I had suffered a brain injury and had a lower leg amputation. He was prone to depression and developed an increasingly severe dependence on alcohol. He resented contact from the services and was aggressive to visitors including the regular care staff who had been commissioned by the Local Authority to provide daily support and monitoring. His case was transferred from the Local Authority Long Term Team (LTT) to the Mental Health Review and Reablement (R&R) Team in June 2013, but despite their best efforts the new keyworkers struggled to develop a working relationship with him. Mr I was assessed as having the mental capacity to make decisions about his health and welfare. The keyworkers took his case to the Risk Enablement Panel (REP) in April 2014 hoping that the case would be transferred, however the REP instead encouraged them to continue with their attempts to engage Mr I. However no meaningful work was possible due to Mr I’s use of alcohol and reluctance to engage, and so it proved very difficult to reduce the risks involved.

The daily carers continued to call but often did not manage to see Mr I, so the police would occasionally be asked to undertake welfare checks. In July 2014 it was agreed by the workers and managers of both teams that the case should be transferred back to the LTT and held on duty (as opposed to being allocated), however due to other work pressures the mental health keyworker did not progress the transfer. In April 2015 the keyworker took the case back to the REP who agreed that the decision to transfer the case back to the LTT should be progressed. However the usual procedures for handover recording and case transfer on the health and the Local Authority IT systems were not completed correctly by the R&R team.

At this time a significant re-structure of the Local Authority teams resulted in the LTT duty function being provided by the Single Point of Access (SPOA) team. A period of confusion and increasing frustration between teams followed. The case began to be managed by the SPOA but they had no access to the recent mental health records and the transfer had not been formally confirmed. This led to a lack of clear accountability for the case. During this period the teams were unaware that Mr I’s physical health was significantly deteriorating. He died unexpectedly in June 2015 and was found in his home several days later by the police.

Details here:

icn_pdf MR I Final Report 2016

Ms C (Somerset)

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. Decision taken not to publish this report, as Ms C and children are all alive, being actively worked with and despite attempts at anonymity, detail within report would be too recognisable

More details here:

Practice Briefing Note Ms C

Tom (Somerset)

In June 2016, the Board received the Serious Case Review concerning a man who, in his early twenties, sustained a traumatic brain injury in a road traffic accident.  Tom took his own life in 2014, aged 43.  A Practice Briefing Sheet has been produced by the SSAB together with the author of the review, outlining the key themes and findings to emerge from the review.  The full review will be published following completion of a Coroner’s enquiry later in 2016.

More details here:

Practice Briefing Note Tom

Mr. AA (Norfolk)

Mr. AA was a Norfolk resident, aged 42 years. He was diagnosed as living with paranoid schizophrenia and had received mental health services over a long period of time. At the beginning of 2014 he went into a period of decline and died in a Suffolk hospital in January 2014. The cause of death was bronchopneumonia but concerns were raised about the intervention he received up until the time of his death. As a result a SAR was commissioned, in partnership with Suffolk SAB.

More details here:

Full Report

Ms B (Hampshire)

Ms B was a 46 year old woman who had a mild learning disability, personality disorder and epilepsy. She was a Portsmouth City Council client who lived in a residential home in Hampshire. She was born on 05/03/68 and died on 12/09/14 at Queen Alexandra Hospital. In this case Ms B’s care and support in the last weeks of her life had involved a complex mix of physical and mental health and care services. Her behaviour had changed significantly and different approaches to respond to this were attempted, but with limited success. Finally her physical health required her admission to hospital and was found to have deteriorated so substantially that little effective treatment was possible. This sequence of events was thought to bring Ms B’s case within the requirements of s44 of the Care Act 2014 as it was appropriate to examine more closely how well the partner agencies and systems in place had worked in responding to Ms B’s needs

HSAB - Report of the Workforce Subgroup  Ms B Safeguarding Adult Review Report December 2015

Ms B Safeguarding Adult Review Executive Summary (December 2015)

CS (Oxford)

CS, an 18-year-old young man, was found submerged in the bath at his residential unit on 4 July 2013. Staff administered CPR and he was transferred by ambulance to hospital accident and emergency department but sadly died later the same day. He had Klinefelter syndrome and experienced learning disabilities, autistic traits and epilepsy and tonic clonic, partial and absence seizures.

CS was admitted to a specialist unit on 19 March 2013. This is a seven-bed in-patient facility for adults with learning disabilities, mental health problems and/or challenging behaviour. At the time of admission, CS was under medication for his epilepsy and his care plan said he should be checked every 15 minutes during baths to ensure he was ok. On the morning of 4 July CS was found submerged in the bath. He sadly died later the same day. Southern Health Foundation Trust commissioned an independent review in November 2013 into the care and treatment provided to CS up until his death. A summary of the professional learning is summarised below:  

Professional Learning

  • Epilepsy profiles should be completed for anyone admitted to the trust with a history of epilepsy.
  • Risk assessments should always be undertaken to ensure risks such as bathing arrangements are identified and addressed.
  • Professionals ask service-users’ families and carers for information about risk and include it in that person’s risk profile.
  • Staff working with patients with a history of epilepsy have access to appropriate advice and support from epilepsy specialists.
  • All relevant staff should be competent to manage an epileptic seizure and be trained in life support.
  • The Assessment and treatment inpatient care pathway should be followed to ensure a patient-centred planning meeting is carried out within three weeks if none has been carried out within the previous six months.
  • All in-patients should have a medical review on admission.
  • When a patient is subject to an emergency admission and is unknown by the unit or community team, a comprehensive assessment of the family or carer’s knowledge and experience of the patient should be undertaken.
  • Clinical teams should ensure that families and carers are fully engaged in the planning and delivery of care.
  • Organisations should ensure collaborative working across inpatient and community services, agreeing models of inter-team working with commissioners.
  • A process for evaluating incidents involving resuscitation (by a resuscitation specialist) should be implemented.

Alice Porter (Northamptonshire)

On 20th April 2011 Alice was being accompanied by Mencap staff to attend church when she fell. The Mencap staff called an ambulance and, despite some initial discussions about whether to take Alice home, the ambulance crew took her to hospital for assessment. Alice was admitted to Northampton General Hospital on 20th April 2011, where she died on 26th May 2011. Alice was 54 when she died. Serious concerns were raised about the care and attention Alice received from both East Midlands Ambulance Service and Northampton General Hospital in the time between her fall and her death. Northamptonshire County Council received three safeguarding alerts regarding Alice’s care while Alice was in hospital. Northampton General Hospital undertook a serious incident investigation and the findings from this and from the safeguarding investigation were considered by an Adult Safeguarding Case Conference on 27th July 2011. EMAS also undertook a serious incident investigation and the case conference found neglect in respect of both East Midlands Ambulance Service and Northampton General Hospital. The circumstances of Alice’s care were escalated to the Northamptonshire Safeguarding of Vulnerable Adults Board, who decided that a serious case review should be undertaken. This decision was taken to better understand the reasons behind a failure to meet Alice’s care and clinical needs and to learn lessons to improve services going forward.

Professional Learning:

  •  Communication – both internal communication and with Alice and her family and carers
  •  Failure to make reasonable adjustments which negatively impacted on the diagnosis and treatment plan for Alice.
  • Failure to properly apply the Mental Capacity Act and make best interest decisions.

These are the same themes that run through the plethora of research documents and inquiries into the health care of people with learning disabilities that have been published over recent years. While it is recognised that these publications have largely been in respect of the ongoing health care needs of people with a learning disability and access to services, it is suggested that the findings could also be applied to emergency interventions. There is resonance with Alice’s experience in particular findings of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD), March 2013 which are summarised as follows:

  • Delays or problems with diagnosis or treatment; problems with identifying needs and providing appropriate care in response to changing needs
  • The lack of reasonable adjustments to facilitate healthcare of people with a learning disability, particularly attendance at clinic appointments and Investigations
  • GP referrals commonly did not mention learning disabilities and hospital “flagging” systems to identify people with learning disabilities who needed reasonable adjustments were limited
  • Professionals in both health and social care commonly showed a lack of adherence to and understanding of the Mental Capacity Act 2005, in particular regarding assessments of capacity, the process of making “best interest” decisions and when an Independent Mental Capacity Advocate (IMCA) should be appointed
  • Despite numerous previous investigations and reports, many professionals are either not aware of, or do not include in their usual practice, approaches that adapt services to meet the needs of people with a learning disability
  • There is a continuing need to identify people with learning disabilities in health care settings and to record, implement and audit the provision of “reasonable adjustments” to avoid serious disadvantage
  • Communications within and between agencies need to be improved It is evident, and it is acknowledged, by those involved in Alice’s treatment


Orchid View SCR report

The report of the Serious Case Review into Orchid View has been published. The review was launched last October after an inquest found that neglect at the West Sussex home had contributed to the deaths of five residents and that a further 14 had received ‘sub-optimal’ care.  The report makes more than 30 recommendations.

Professional Learning:

  • Private care homes being required to provide they can sustain a skilled workforce.
  • Care providers should be required to demonstrate that they have robust plans for recruiting and sustaining a skilled workforce to the Care Quality Commission (CQC).
  • Agreement of  thresholds and a system for alerting relatives about safeguarding concerns at homes so that they can make “informed choices” about where to place their loved ones.
  • CQC should name homes that lack a registered manager on its website.
  • CQC to do more to get the views of relatives in its inspections, including providing them with the opportunity for private discussions about any safeguarding concerns they may have.

June 2014 Orchid View Serious Case Review Report

Learning Review into Deaths of Vulnerable Young Adults

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.

Somerset Learning Review June 2014


St Michaels’ View (South Tyneside)

Southern Cross Health Care operated at St Michael’s View with a culture that had no effective measures in place to prevent abuse and neglect. There was a lack of clear governance, direction and oversight from managers, nursing and care staff. There was lack of effective workable policies and procedures. In addition there appeared to be a lack of awareness of whistle blowing procedures or any effective safeguarding training to support staff to raise appropriate concerns in line with their safeguarding responsibilities. Therefore the voice of the resident was not apparent.

Professional learning:

  • There were lessons also to be learned across wider services responsible for regulation, commissioning, monitoring and/or delivering services to vulnerable adults which should have identified these problems earlier.
  • Hospital based processes could have been strengthened to recognise when safeguarding alerts should have been made when vulnerable adults were subject to repeated admissions to hospital from a care home.
  • There was a need to strengthen commissioning, quality assurance and monitoring processes so that they are sufficient to identify and address opportunities for intervention when abusive or neglectful practice is suspected.
  • The importance of relatives having clear information about safeguarding protocols and where to get help external to the care provider when they had complaints about the care of their relatives.
  • Recognition of the collective impact of consistently poor standards of care practice with regard to the dignity and respect of residents.

2013 December SCR regarding St Michael’s View (South Tyneside)

Mr A (Hampshire)

Mr A had a learning disability and was 52 years old when he died at the Queen Alexander Hospital, part of Portsmouth Hospitals Trust (PHT) on 31st May 2010. Many agencies had been involved in Mr A’s care prior to his death and it was considered that an SCR would be the best approach in which to capture learning on a single and multi-agency basis. 

Professional learning:

  • The SCR highlighted critical failings in the care and support of Mr A in both community and acute NHS settings and issue regarding his support planning and review. These have been addressed through the development of single and multi-agency actions plans the implementation of which has been monitored via the Hampshire Safeguarding Adults Board.

2013 June Serious Case Review regarding Mr A (Hampshire)

Mr J (Kent)

Mr J was a fifty-nine year old vulnerable adult living in supported temporary housing after a period of homelessness following the breakdown of his marriage. In May 2008 he saw his GP and reported that his memory had deteriorated dramatically and that he used to have an alcohol problem. He was referred to mental health services where it was found that he had Alzheimer’s disease. Mr J was treated with medication and monitored. It emerged during 2008 that Mr J was experiencing difficulties with other residents at the supported housing and their associates. These people were variously said to be prostitutes and drug users. There were reports of thefts from Mr J which were investigated by police. Mr J would not agree to criminal charges being brought. It was judged that Mr J was able to live more independently and he moved on from the temporary accommodation he was in and he moved to alternative accommodation. In early 2009 police became aware of concerns he was still being exploited by acquaintances he had met at his previous accommodation. Police were involved in criminal investigations when Mr J made allegations against these people but he subsequently withdrew the allegations or they could not be substantiated. He was seen twice in the Accident & Emergency Department with facial injuries, which he insisted had been caused accidentally. Mr J was subject to a safeguarding referral which resulted in him moving to a care home on a temporary basis as a place of safety. After a short period, Mr J moved back to his own home. Monitoring visits found Mr J not be coping well. There were indications of excessive drinking, disorientation and inability to manage personal care needs. Two weeks after returning home, Mr J was taken to hospital where he was found to have multiple cuts, bruises and possible pressure sores of varying ages, and to be extremely dehydrated. He had multiple injuries to his brain. He deteriorated further and died in hospital four days later.

Professional learning:

  • The importance of relationship building with difficult to engage people or those at risk of exploitation.
  • The importance of addressing isolation and supporting service users to strengthen or re-establish family/social networks as a means of protecting from further harm/exploitation.
  • The importance of involving the GP and also having a GP when leaving residential care.
  • There was no process of care planning, assessment and review.
  • Input from professionals lacked direction and purpose, and was not alert to the safeguarding dimension of the situation.
  • The need for clear and robust risk management and understanding as to the threshold for referring issues into the safeguarding procedures.
  • There was a confused approach to the implementation of safeguarding arrangements once it became clear that Mr J was being exploited and abused. There was a lack of compliance across agencies with basic safeguarding procedures relating to the notification, recording and follow up of safeguarding concerns.

2013 June Serious Case Review regarding Mr J (Kent)

Gloria Foster (Surrey)

Mrs Foster was left alone for nine days without her essential privately funded care and support service when the provider company ceased trading. She died eleven days after being discovered by a visiting district nurse and her admission to hospital. Police investigations concluded the action or lack of action of any person did not meet the criminal threshold of wilful neglect or ill treatment. The actions involved, or rather inaction, were not intentional or deliberate. Nor can the employing council be shown, at senior manager level, to have criminally breached their duty of care. The SCR found that Mrs Foster would have benefited from better multi-agency care coordination and review from August 2009. Besides offering a potential improvement to the quality of her life this may have avoided her falling victim to events.  The provider failure protocol subsequently put in place by Surrey addresses the necessity to treat service closure as a significant occurrence demanding of focussed leadership. It includes, for example, the use of timed handover logs and scheduled debriefings that would have picked up the omissions that left Mrs Foster without home care for nine days.

Professional learning:

  • The need to have in place a Provider Failure Protocol which recognises service closure as a significant occurrence.
  • The need for clear policy and practice guidance regarding people returning home to improve multi-agency coordination of care.
  • The need for an access policy and procedure (for support health professionals who undertake home visits and need to gain entry) that combines the need for privacy, security and ease of entry.
  • The need to promote the use of assisted living technology in improving quality of life and personal safety.

2013 September Serious Case Review regarding Gloria Foster (Surrey)

Mrs D (Coventry)

Mrs D died following an accident and a brief period of treatment in hospital and the community. The injury which Mrs D sustained falling from her wheelchair in the summer of 2011, resulted in a period of hospitalisation and a decision to treat her neck injury using a supporting neck collar. The collar itself caused friction to her skin resulting in the formation of a pressure ulcer. This ulcer in turn eventually became infected and Mrs D died as a result of the septicaemia, or infection based blood poisoning which it caused. Mrs D was an elderly woman with a number of disabilities and health concerns prior to the incident which ultimately led to her death. She was extensively supported by her family. This serious case review examines the underlying causes of Mrs D’s death and provides recommendations to reduce the likelihood of their recurrence in the future.

Professional learning:

  • There were some significant shortcomings in the assessment, care, treatment and services provided and some missed opportunities for closer working between agencies providing care.
  • A positive and proactive approach to joint working is in the best interests of those receiving services, as well as basic standards of care being effectively and comprehensively delivered.
  • Families should be listened to as much as necessary, and have the opportunity to make a contribution within formal care environments alongside health and social care professionals.
  • Staff should ensure that carers have an opportunity to express concerns and have those concerns responded to in a timely fashion.

2013 Serious Case Review regarding Mrs D (Coventry)