Safeguarding Adults Cases, Reports and Reviews
This is a summary of cases where adults at risk, sometimes known as vulnerable adults, have been abused in some way. The purpose of the list, of course, is for professionals and others to learn what went wrong, in the hope that such abuse is less likely to happen again in future.
We list here some of the most interesting and significant cases. The list is regularly updated as new cases come in, the most recent cases being nearest the top of the list. If you have any suggestions of cases you would like us to include please let us know.
We naturally update our Safeguarding training to take account of such cases.
Mr D was a young man with learning disabilities who experienced neglect by his family and by professionals who were involved in his care. He was seriously overweight, and was admitted to hospital with a Grade 4 pressure sore (the most serious kind).
Ms Taylor was a 71 year old woman with multiple mental and physical health needs who died in a fire at her own home in 2017. She was a heavy smoker, and there had been concerns prior to her death about possible fire risks. A recommendation that she be provided with flame-retardant bedding had not been actioned.
Ms F, a 44 year old woman with Multiple Sclerosis, developed a serious pressure sore as a result of a faulty profiling mattress, and then delays in providing her with appropriate care.
Nightingale Homes ran 3 residential homes for adults with learning disabilities and mental health needs. During 2015 and 2016 significant concerns were raised about the running of these homes, which led to a CQC rating of "inadequate", and the homes eventually closed in 2017. The SAR looked at what had gone wrong, as the organisation had been in business for many years, and its homes had previously been rated as "good".
Two adults with profound learning disabilities sustained injuries that were probably caused by incorrect moving and handling techniques.
This was the death of a 25 year old woman with various care and support needs who had been placed in Bedfordshire by Sussex Partnership NHS Foundation Trust. Miss A died in a road traffic accident at 3am in July 2016.
A 32 year old man with foetal alcohol syndrome and other conditions who hanged himself after being informed that he could not remain living in his deceased father's council property.
A 40-year-old woman with schizophrenia as well as alcohol and self-neglect issues died at home in 2012. The SAR criticised, amongst other things, poor multi-agency working.
Two unrelated deaths of adults with care and support needs, but there was a common thread of self neglect, which is why the reviews were published simultaneously.
64-year-old man died after refusing medical treatment, review criticises professionals for a "lack of legal literacy".
A 39-year-old woman with multiple care and support needs, including self neglect and alcohol problems, was murdered in her own home in December 2014 by two teenage girls.
The death in a road traffic accident of a 35 year old woman who had various mental health and emotional issues.
A 61-year-old man with self neglect and mental health issues died in a fire in his own flat in 2014.
Patient A, who had a history of self neglect, died in 2015, and the Adults Practice Review expressed concerns about communication, referral pathways, clinical examination & treatment, care co-ordination and strategic issues.
A review of the neglect of older people living in various care homes across Wales, which was investigated by the police as "Operation Jasmine".
Death of an elderly lady who often left her home in bad weather to visit her husband who was living in a nearby residential home.
Richard Handley (who is called "James" in the review) was a 33-year old man with a learning disability who died in hospital in Ipswich due to severe constipation.
Death of a 42 year old man who had a long history of mental health issues and who died in Ipswich General Hospital. This report contains a useful chart of how the SABs (Norfolk and Suffolk) have responded to the recommendations made in the Report.
72 year old man died after discharging himself from hospital (report compiled by St Thomas Training).
Institutional abuse and neglect at a care home for elderly people, many of whom had dementia.
Death of a 79 year old man following an extended period of self neglect. Lots of agencies involved in his life, but lack of co-ordination meant the response wasn't as effective as it could have been.
Death of a resident of a registered care home, following an assault by another resident.
A disabled Iranian asylum-seeker was beaten to death by a neighbour who wrongly suspected him of being a paedophile. A follow up report in 2017 by the Safer Bristol Partnership accused the police and the council of "institutional racism" in this case.
Death of an 86 year old man who had been neglecting his own care at home, and was eventually admitted to a care home and then to hospital.
81 year old lady with various health conditions "slipped though the net" when her home care was withdrawn.
A case where the local authority was heavily criticised by the Court for its unreasonable delay in dealing with a Safeguarding issue.
A 27 year old woman with learning disabilities who was "befriended" by a group of 5 young people who tortured and bullied her, and ultimately murdered her. (This link contains the report itself, and also a summary of what action has been taken in reponse to the report's recommendations).
Undercover filming by BBC uncovered systematic abuse of residents with learning disabilities near Bristol.
A mother and her learning disabled daughter experienced 10 years of abuse and harrassment from neighbours, which ended in the mother taking both their lives.
39 year old man with learning disabilities murdered by 3 people who took over his life and property.
78 year old lady died at the hands of her relatives, but none of them could face criminal charges because it wasn't clear who was responsible. Led to S44 new criminal offence under the Mental Capacity Act.