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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)


Sasha Safeguarding Adult Review Learning Summary – March 2021

To build on the work already undertaken by partners since publication of the Sasha SAR, the HSAB has developed the briefing  linked below which specifically addresses learning relating to the understanding and application of Mental Health Act and Mental Capacity Act specifically where a person is presenting with severe self-harm and suicide behaviour and is refusing treatment:

SAR Learning Point 6: The Provisions of the Mental Health Act should be applied robustly in order to ensure safety and treatment. This will prevent confusion as to the status of a detained person as well as clarity regarding use of the Mental Health Act and/or Mental Capacity Act.

SAR Learning Point 7: Mental Capacity needs careful and robust assessment where a person is presenting with severe self-harm and suicide behaviour and is refusing treatment.

SAR Learning Point 8: Advance decisions should always attract questions and seeking of legal advice in cases of self-harm and suicidal behaviour.

This briefing is intended as a useful tool to support and guide for staff working in this particularly complex and challenging area of practice.

Sasha Safeguarding Adult Review – Learning Summary