Other SAB SAR Lesson Learnt Briefings
Joanna, Jon and Ben published by Norfolk SAB
Joanna was admitted to Cawston Park under S.3 of the Mental Health Act during Oct 2016, she died 17 months later at the age of 36.
Jon died 11 months after being admitted to Cawston Park at the age of 33.
Ben was 32 when he died 24 months after his admission to Cawston Park.
Joanna and Jon originated from London boroughs. Ben was from Norfolk. Their behaviour was known to challenge services and sometimes their families. Joanna and Jon had experienced several out-of-family-home placements. Ben had lived with his mother for most of his life. Their placement at the hospital resulted from personal and family crises. It was the only placement which could be identified by Joanna’s Clinical Commissioning Group (CCG) which had previously contacted 38 other services.
SSAB SAR Learning Briefing – Joanna, Jon and Ben
Damien published by Somerset SAB
Damien had diagnoses of Asperger’s Syndrome and ADHD. He had a mild learning disability and misused a variety of substances, causing him to come into frequent contact with the police and mental health services.
Learning from SARs: A report for the London Safeguarding Adults Board By Suzy Braye & Michael Preston-Shoot
This review considered the nature and content of 27 SAR’s commissioned and completed by London SAB’s since the implementation of the Care Act 2014 on 1st April 2015 up to the 30th April 2017. The learning identified related to four key domains of the safeguarding system which are listed below along with key areas for improvement
Mendip House Published by Somerset SAB
The National Autistic Society (NAS) were the Registered Managers of Somerset Court Campus, a 26-acre plot with seven registered dwellings plus outreach and day services for adults with autism. Mendip House was one of the registered homes, providing accommodation and specialist support for six adults with autism.
In May 2016, personnel from Somerset Safeguarding team and the CQC became aware of incidents of bullying following anonymous reporting. Subsequently a review took place which identified;
- taunting, bullying, mistreatment and humiliation of residents;
- financial abuse;
- missing medication; and
- poor oversight of staff
SSAB SAR learning – Mendip House
Adult C published by West Sussex SAB
In April 2015, two male residents of the same care home in West Sussex, Adult C (30 years) and Adult D (63 years) were taken to the Emergency Department of East Surrey
Hospital. Both have profound learning difficulties, cerebral palsy and suffer from osteoporosis.
Each was subsequently found to have suffered fractures to a femur and were admitted to the hospital where they remained for several months before being resettled in different care homes.
Whilst the care home (Beech Lodge) was located in West Sussex, the placing authority for Adult C was Surrey County Council (Mole Valley).
The West Sussex Safeguarding Adults Board commissioned a joint Safeguarding Adult Review in July 2016 into the care of both Adult C and Adult D. The focus of this learning briefing focuses predominantly on the recommendations for Surrey in relation to Adult C, however it is also mindful of the wider findings in relation to the injuries to both vulnerable adults.
SSAB SAR learnings – Adult C West Sussex
Adult B Published by East Sussex SAB
The East Sussex Safeguarding Adults Board (SAB) published the findings of a Safeguarding Adult Review (SAR) following the death of a 94-year-old lady in September 2017, referred to as Adult B. The lady died in hospital of natural causes but, when admitted, was found to have 26 unexplained injuries including a fractured nose and jaw, as well as old and new bruising to her face, arms and legs. She was diagnosed with sepsis and pneumonia shortly after her arrival in hospital and she died eight days later.