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James SAR

Date: Wednesday, 05th May 2021 | Category: Uncategorized

This Safeguarding Adults Review relates to the death of a young man referred to as James. James was a 42-year old man who suffered an acquired brain injury in 2010, which led to him developing significant care and support needs and subsequently receiving assistance from a range of statutory and non-statutory agencies when he returned to independent living. The issues that James experienced included substance use, self-neglect, financial abuse, exploitation and ability to make capacitated decisions following his acquired brain injury. James passed away in July 2019 from a cardiac arrest linked to drug use.

This SAR was commissioned by the BHSAB to consider whether there was sufficient understanding and awareness of James’ acquired brain injury and the impact of this, as well as the policies and procedures currently in place to support individuals with acquired brain injuries. The reviewer was also tasked with exploring whether wider existing policies and procedures were appropriately followed and whether any specialist support was sought in responding to James’ needs, as well as how learning could be effectively taken from what occurred.


The review notes that James was difficult to engage and would often not co-operate with services, and that agencies broadly acted in accordance with their internal and multi-agency policies. However, it also identifies that in the main there was little evidence of a jointly agreed care plan or multi-agency working being co-ordinated and managed by a lead professional.

It states that there wasn’t any consideration of wider professional guidance or specialist resource being sought, despite many of James’ problems stemming from his acquired brain injury, and that, ‘the absence of formal capacity assessments meant there was insufficient understanding of how ABI (acquired brain injury) was affecting James’ substance misuse and vice versa and the implications of this for his capacity to care for himself effectively.’


The full report can be accessed here:  James SAR Final Report.


The reviewer identified that there is a need for all agencies to develop a greater awareness and understanding of the effect of brain injuries on an individual as well as a need for commissioners of services to consider how to enable existing services to be developed to meet these needs.

The review concludes that, ‘the assessments undertaken of James’ needs did not take sufficient account of his ABI and in particular the absence of capacity assessments informed by expertise in brain injury meant that the care provided to him was ineffective.’ This was due to, ‘a lack of specialist expertise within the multi-agency system to assist practitioners undertaking such work’ and that ‘the procedures and training currently provided to practitioners are insufficient.’

This review makes seven recommendations, with Health and Social Care commissioners asked to develop and improve services for people with acquired brain injuries, that includes specialist guidance pathways and more effective support around substance misuse. The local authority are requested to provide specialist training around mental capacity processes in working with people with acquired brain injuries. The BHSAB will seek to effectively share the learning from this review, update relevant policies and procedures as well as consider future assurance activities to review the learning and effectiveness of the lead professional role. The Safeguarding Adults Review Subgroup is currently working with partner agencies to develop a multi-agency action plan to take forward these recommendations.


The Independent Chair of Brighton and Hove Safeguarding Adults Board, Graham Bartlett said,

‘Brighton and Hove Safeguarding Adults Board fully accepts this review and offers its condolences to James’ family. The review highlights the need for professionals to be supported with expert guidance and resources, especially where clients have suffered ABIs and the need for a single coordinating professional to ensure that the needs of the individual are understood and met. The death has similar themes to that of ‘Christopher,’ a SAR we published in March 2021, and we will ensure the learning from both is shared and embedded to help those who these services are there to support.’