Published Safeguarding Adult Reviews (SARs)
Eden (September 2024) – In relation to an unexpected death
Eden was a creative individual and had so much potential to become a great author, artist and animator. She was also a voice for survivors of sexual abuse and used her artistic and writing skills in order to express her experiences in a manner suitable for young children and teens to comprehend, as well as take note of the warning signs before anything serious could happen.
Publication Statement from the SSAB Chair
Executive Summary Report
Rose (April 2024) – In relation to an unexpected death
Rose had been known to services in Surrey for most of her life, she had experienced significant adverse childhood experiences, including offending behaviour which led to incarceration and homelessness.
Publication Statement from the SSAB Chair
Summary Report
Statement from Rose’s mother
Railway Guardian Campaign Toolkit
Ella (March 2024) – In relation to an unexpected death
Ella was a 33-year-old woman who took her own life on 13th October 2018 while an informal inpatient at the Abraham Cowley Unit in Chertsey, run by the Surrey and Borders Partnership NHS Foundation Trust (SaBP).
Publication Statement from the SSAB Chair
Executive Summary
Louise (February 2024) – In relation to an unexpected death
Louise was discovered by Surrey Police to have died at home, with some evidence to suspect that this was caused by an overdose of medication. She had been known to mental health services and had recently been discharged from a psychiatric hospital admission under S2 (MHA ’83) less than a week before she died.
Publication Statement from the SSAB Chair
Executive Summary
Zahra (February 2024) – In relation to an unexpected death
Zahra was 55 years old when she died as a result of an accident in November 2020.
Zahra came to the UK from another country in 1999, English was not her first language and she struggled to understand and be understood by others. Due to this she may have felt isolated, it appears that she began to drink large quantities of alcohol as a result.
Publication Statement from the SSAB Chair
Executive Summary
How to use legal powers to safeguard highly vulnerable dependent drinkers | Alcohol Change UK
Peter (September 2022) – In relation to an unexpected death
Peter was a 50-year-old white, British male with a number of physical health conditions. He also had a history of alcohol abuse, which impacted on his mobility, ability to manage his self-care, remember to take medication and his behaviour.
He regularly displayed aggressive and reckless behaviours when inebriated; often this resulted in a need for medical care, loss of accommodation or criminal charges.
Publication Statement from the SSAB Chair
Executive Summary
Full Report
Applying the Lessons Presentation – June 2023
Surrey & Borders NHS Partnership – June 2023
Surrey County Council, Adult Social Care Presentation – June 2023
Surrey Adults Matter (SAM) Presentation – June 2023
How to use legal powers to safeguard highly vulnerable dependent drinkers | Alcohol Change UK
Person 1 (November 2020) – In relation to a patient on patient attack at a nursing home
Person 1 (P1) was a 92-year-old woman with ‘end stage’ dementia, who was reported to police as being subjected to a violent physical assault in her room at a residential care home, whilst in bed and unable to mobilise.
Police reports documented that P1 was assaulted by a male resident aged 94, who had dementia and a recorded history of violence and aggression towards residents and staff, at the care home.
Publication Statement from the SSAB Chair
Executive Summary
SAR Report
Sasha (Hampshire SAR) May 2020 – In relation to multi-agency working
Sasha was 20 years old and had a long history of mental health illness and missing episodes since the age of 15. Before her death, she was under the care of several health services and as a child had been supported by the Child and Adolescent Mental Health Team (CAMHS).
On the evening she died, Sasha was found in a serious condition by a lake in a country park close to where she lived. She died shortly afterwards in hospital from a suspected overdose of propranolol.
The Coroner confirmed that Sasha died as a result of suicide following a deliberate fatal overdose of propranolol tablets.
SAR Report
SSAB SAR learnings – Sasha. Review by Hampshire SAB
Mr J and Mr Y (2016) – In relation to concerns of an incident of patient on patient attack at a nursing home
Mr Y was a man in his 90s who had been diagnosed with Alzheimers Disease in 2009. In April 2012 his condition had become more advanced and he moved to XX Care Home. XX is a care home with nursing that specifically looks after people who have a mental illness, including dementia (or Alzheimers) many of their residents are older people who have dementia.
Mr J was a man in his 70s. In March 2013 (before he moved to XX) it had been reported he was experiencing memory problems. He attended the Memory Assessment Service where he was described as a ‘cheerful, light hearted gentleman and cooperative if lacking insight’.