Sasha (May 2020)

Safeguarding Adult Review Report for Sasha

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 2017 of Sasha, a young adult.

Firstly, the HSAB would like to express sincere condolences to Sasha’s family for their tragic loss. The family has been involved throughout the review process and it is at their specific request that we have used Sasha’s real name. The Family were invited to provide a statement to accompany publication of the final report and this can be found at the end of this brief statement.

The circumstances of Sasha’s death and her history of contact with a wide range of agencies, gave rise to serious concerns. In response, the HSAB commissioned an independently led Safeguarding Adult Review to establish any learning about the way in which local professionals and agencies worked together to safeguard Sasha. 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:

  • Management of cross boundary working.
  • Transition pathways to ensure these are person centred and provide clear transition plans.
  • Early recognition and diagnosis of Autism Spectrum disorders to ensure right approaches and treatment.
  • Protocols for managing people who access services on a frequent basis.
  • Use of multi-agency risk panels to share information to inform the formulation of multi-agency plans to help mitigate identified risks.
  • Guidance to support professionals with understanding advanced decisions and high risk and complex cases that they do not face very often.
  • Understanding and application of the Mental Health Act and the Mental Capacity Act where a person is presenting with severe self-harm and suicide behaviour and is refusing treatment.

Sasha SAR – Family’s Statement

Sasha SAR Final Overview Report (HSAB)

Sasha SAR Executive Summary Report (HSAB)