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Vicky (September 2021)

The HSAB is pleased to publish this important Safeguarding Adults Review (SAR) that provides an insight into the circumstances of a young woman (Vicky) who lived with a difficult combination of challenges, having developed epilepsy when she was eighteen and subsequently in later life also developing mental health and substance misuse issues. Vicky lived most of her life in Hampshire but towards the end of her life she became homeless and moved into the Portsmouth area looking for accommodation. We would particularly like to acknowledge the valuable contribution of colleagues from Hampshire and also the Portsmouth agencies to the review process.

Very sadly Vicky died on her own in Bed and Breakfast accommodation. Her death was not directly linked to abuse or neglect, but the HSAB felt that there were important areas of learning about how the local systems responded to Vicky’s circumstances and so this discretionary SAR was commissioned.

The key areas of systemic learning that are explored in the review include:

  • working with adults who are ambivalent about engaging with services,
  • managing safeguarding in situations of long-term chronic risk,
  • considering issues of mental capacity assessment and the value of multi-agency input to the assessment process,
  • the commissioning challenges related to providing support packages to homeless adults who are eligible for support and
  • the importance of effective communication between primary and secondary health teams particularly when an adult is needing to manage multiple issues such as mental health concerns and epilepsy.

The HSAB would like to acknowledge the active contribution of Vicky’s family in the review process, in addition to the work and time given by practitioners and frontline managers from all agencies who were actively involved in the review process.

The HSAB and partner agencies have begun work on the action plan and will provide an update on the improvements made in our spring 2022 annual report.

Graham Allen

Hampshire Safeguarding Adult Board Chair.


PDF icon Vicky SAR Report – HSAB September 2021

PDF icon Vicky SAR Learning Summary Report – HSAB September 2021