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Learning from Experience Database - Serious Case Reviews

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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