This Safeguarding Adults Review (SAR) concerns the death of Christopher, a 39-year old man with a history of anxiety, learning disability and substance use. At the time of his death he was living in temporary accommodation and was receiving support from a number of local services.
Christopher died in March 2017, A referral was subsequently made to the BHSAB in 2018 and it was agreed to commission a SAR. This decision was made as it was considered that the statutory criteria that had been met; namely that an adult had died as a result of abuse or neglect, whether known or suspected, and there was concern that partner agencies could have worked together more effectively to protect the adult.
The report makes note of a lack of safeguarding interventions in the two years prior to Christopher’s death, despite evidence of self-neglect and questions about Christopher’s capacity to care for himself and make safe decisions. The report concludes that significant support was provided by a range of agencies during this period, and lack of resources was not obviously the reason for non-intervention by professionals. Rather assumptions made about his capacity to make safe decisions and a reluctance to intervene or to challenge Christopher’s view of the world.
This SAR has examined practice from some time ago, and it is reported that there have been significant improvements in terms of training and changes in service delivery. The challenge is to be confident that this input has resulted in changes in practice and better outcomes for service users.
The full report can be accessed here: Christopher SAR Final Report .