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Ms E (April) (June 2020)

Safeguarding Adult Review Report for April

Statement from the HSAB Chair

The Hampshire Safeguarding Adults Board (HSAB) has today published an independent Safeguarding Adults Review (SAR) into the circumstances surrounding the death in 2019 of April, an older adult.

Firstly, the HSAB would like to express sincere condolences to April’s family for their tragic loss. The family has been involved during the review process and it is at their specific request that we have used April’s real name.

The circumstances of April’s death and her history of contact with a number of agencies prior to her death, gave rise to serious concerns. In response, the HSAB commissioned an independently led SAR to establish any if any learning could be gained about the way in which local professionals and agencies worked together to safeguard April. As well as highlighting some good practice, the SAR also identified important learning and key areas for further improvement. HSAB accepts in full the recommendations in the report and we will now be working with partner agencies to share and embed this learning within respective organisations and to deliver improvements in the key areas identified in the recommendations. We expect the learning from this SAR to bring about positive change and improvements in the following areas:

  • The diagnosis of fractures in frail, elderly people (particularly those without a history of fractures) to ensure that the treatment offered is appropriate and timely.
  • Effective multi-disciplinary working and care planning within health services to ensure that clinical errors or misdiagnoses are prevented or identified at an earlier stage.
  • Ability to maintain a greater level of continuity of the staff working with the adult and the benefit this brings in terms of enabling a positive relationship to be established with the adult and the ability to ensure personalised care.
  • Knowledge and understanding within health services to ensure appropriate support and equipment is accessed in a timely way to meet the adult’s specific care needs.

Graham Allen

Chair, Hampshire Safeguarding Adults Board


April SAR Report – HSAB June 2020