Pre-Care Act 2014 Serious Case Review (SCR)
Mr J and Mr Y Published January 2016
Following an incident in a nursing home when a man with dementia (referred to as Mr J), assaulted another resident (referred to as Mr Y). Mr Y was taken to hospital where he died 3 days later.
Mr D Published July 2014
Mr D was 84 years old when he became known to statutory services in 2008.
The adequacy of the care he received as he physically deteriorated and became doubly incontinent, the quality of assessments and associated planning and responsiveness to concerns raised.
Mrs A Published March 2014
Mrs A was a talented musician who committed suicide after giving evidence in a historic sexual abuse trial in which a teacher and his wife were convicted of offences against her.
Mrs S Published March 2014
Mrs S died during June 2012 at East Surrey Hospital, Surrey and Sussex Healthcare NHS Trust. A patient at Shrewsbury Court Independent Hospital since 2007, Mrs S was 75 years old when she was admitted to Intensive Care in East Surrey Hospital.
Mrs S had been clearing her plate away when she was spoken to by a member of staff. She was unable to respond and found to be choking. CPR…commenced. Paramedics managed to dislodge the food.2 Mrs S was subsequently found to have had achalasia.
Gloria Foster Published September 2013
In January 2013, Reigate and Banstead locality team of Surrey County Council, Adult Social Care (ASC), was informed by the London Borough (LB) of Sutton of concerns notified by the UK Border Agency (Home Office) in relation to illegal immigrants working for Carefirst241.
Publication Statement
Executive Summary
SCR Report
CC Published – October 2010
CC died in 2009 when he fell from a car park in Woking. He had sustained external trauma to his body as well as a self-inflicted injury to his upper chest. The Coroner gave the cause of death as suicide. CC had a diagnosis of paranoid schizophrenia with secondary cannabis abuse and a personality disorder. He was on an enhanced level of Care Programme Approach at the time of his death.
He was well known to partner agencies including SABP, Woking Borough Council and Surrey Police.
and to the probation service.
0002 Published July 2010
0002 died aged 81 years in a house fire at her home in Surrey in November 2008. She had lived alone since her husband died in 2006 and was supported by her family. She suffered from Chronic Obstructive Pulmonary Disease (COPD) and mild to moderate dementia with the probable diagnosis of Alzheimer’s. She had been known to both adult social care and mental health services since 2005.
0001 Published June 2010
A ‘near miss event in March 2008 within a supported living environment when A was stabbed by 0001 in what appeared to be an unprovoked attack
HL Published September 2008
HL was born in 1949 and at the age of two years diagnosed as suffering from profound mental retardation. In 1956 he was further diagnosed with, “autism” and “psychosis”. As a result his communication skills are extremely limited and he has a history of severe challenging behaviour and self-harming.