Andrew SAR

This Safeguarding Adults Review concerns the death of a gentleman referred to as Andrew. Andrew was a 51-year-old gentleman who had a severe learning disability, in addition to a range of longstanding health difficulties that included existing concerns around nutritional intake and weight loss. He had been living in a local authority residential care home setting for over twenty years but was admitted to hospital after sustaining significant injuries following an assault by another resident. Andrew experienced further illness whilst in hospital and his weight loss continued. On discharge he returned to the Residential Care Home but was readmitted to hospital only ten days later and passed away shortly after this.

The Brighton and Hove Safeguarding Adults Board commissioned a discretionary Safeguarding Adults Review (SAR), in the form of a ‘Desk-top Review’ to understand the circumstances leading up to the death of Andrew and to bring together the various investigative and enquiry processes undertaken by individual organisations involved to identify and share multi-agency learning in seeking to prevent a similar situation occurring again in the future.

The Independent Reviewer grouped their findings into seven themes and made six recommendations. The Brighton and Hove Safeguarding Adults Board have produced an Executive Summary based on the review report to ensure learning from the review is effectively identified and shared.

This Executive Summary includes the key findings in each of the seven themes as well as the six recommendations that were made and can be accessed here: Andrew SAR Executive Summary.